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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001308
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:25:38 PM


Document Has Been Signed on 05/10/2022 03:25 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 GUEST HOME IVFACILITY NUMBER:
306001308
ADMINISTRATOR:CAMBIO, SUSAN & LEONARDFACILITY TYPE:
740
ADDRESS:26972 VIA GRANDETELEPHONE:
(949) 367-1806
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Susan Cambio, Administrator
Leonardo Cambio, Administrator
Urcy De La Cruz May, caregiver		TIME COMPLETED:
03:45 PM
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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 caregiver Urcy De La Cruz May after explaining the purpose of the visit. Licensees Susan Cambio and Leonardo Cambio were notified and arrived shortly afterwards.

At approximately 2:25pm, LPA accompanied by administrators toured the inside and outside of the facility. There are currently five (5) residents in care. Residents are observed relaxing in their bedrooms or in the common area and appear clean and well taken care of. The bedrooms include all necessary components. The bathrooms are equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected.

Sharp instruments are kept in a cabinet secured by a magnetic lock. Cleaning supplies are secured under lock in the attached garage. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted.

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility and observed it to be free of obstructions. A shaded area with outdoor furniture is present to accommodate residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. No bodies of water are observed 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. A Technical Advisory is being issued in regard to staff association and background clearance as well as cleaning solutions storage. This report was reviewed with facility representative and a copy of this report 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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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