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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000873
Report Date: 11/15/2021
Date Signed: 11/15/2021 10:54:06 AM

Document Has Been Signed on 11/15/2021 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BATES FAMILY HOME IIIFACILITY NUMBER:
306000873
ADMINISTRATOR:RANDALL & SANDRA BATESFACILITY TYPE:
735
ADDRESS:26631 ESTRADA CIRCLETELEPHONE:
(949) 458-9315
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Administrator Randall Bates TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Randall Bates and stated the purpose of this visit.

The facility is licensed for capacity of six with two ambulatory and four non-ambulatory.

About 9:52 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, all four clients were out attending respective day program. LPA toured the interior and exterior portions of the facility. There were three shared rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Individual smoke in each room and carbon monoxide alarms were tested to be operational. Bathroom was observed to be in good repair. Hot water was measured at 110 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to clients in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA Marin reviewed the COVID 19 mitigation plan of the facility.

For this visit, no citation has been issued.

LPA Marin conducted an exit interview with AD Randall Bates ; and copies of this report, advisory notes, and California Code of Regulation Section 80075 were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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