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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001028
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:01:15 PM


Document Has Been Signed on 07/22/2022 03:01 PM - 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:GOOD SAMARITAN IIFACILITY NUMBER:
306001028
ADMINISTRATOR:CAMBIO, SUSAN & LEOFACILITY TYPE:
740
ADDRESS:26852 LA SIERRATELEPHONE:
(949) 367-1228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leo Cambio, Administrator
Susan Cambio, Administrator
Rachel May, caregiver		TIME COMPLETED:
03:15 PM
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On 07/22/2022 at 1:45pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Leo Cambio and Susan Cambio, Licensee and Administrator after explaining the purpose of the visit. LPA observed a check-in station at the facility's entrance.

At approximately 2:05pm, LPA accompanied by licensee toured the inside and outside of the facility. There are currently four (4) residents in care, none of which are receiving hospice care. Residents are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The four (4) bedrooms include all necessary components. The two (2) bathrooms are equipped with grab bars and slip mats. The facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen cabinet with a functional magnetic lock. LPA observed a sufficient supply of food and water. The central storage of medication is located in a locked drawer in the kitchen. Cleaning supplies are secured in the locked attached garage. A sufficient supply of linen is observed. LPA observed required department postings and COVID precaution posters on display. Facility has an adequate supply of PPE available. LPA provided a consultation on the requirement for an Infection Control Plan to be submitted. Caregiving staff present is cleared but needs to be correctly associated to the facility.

LPA toured the outside of the facility and observed outdoor furniture in a shaded area on the patio for the enjoyment of residents. The two perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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