306001851-9-12-2022-22-AS-KSGH-CJ7SS5-20220912140723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001851
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:07:32 PM

Document Has Been Signed on 09/12/2022 02:07 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:	KATHRYN JANE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	306001851
ADMINISTRATOR:	ALFONSO/EDILMA AVENDANO		FACILITY TYPE:	740
ADDRESS:	26861 VIA GRANDE		TELEPHONE:	(949) 632-3762
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	09/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Roberto Gamino Castro, caregiver Alfonso Avendano, administrator		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/12/2022 at 12:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by the caregiving staff present and explained the purpose of the visit. Administrator Alfonso Avendano was notified of the visit by telephone and arrived shortly afterwards to assist with the visit. At approximately 1:05pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently five (5) residents in care, two (2) of which are receiving hospice care, which is in compliance with the terms of the approved hospice waiver. Residents are observed enjoying their lunch, relaxing in the common areas or in their respective bedrooms and appear clean and well taken care of. The bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept in a lockbox in the kitchen. Cleaning supplies are stored securely with child-proofing mechanisms under the sink and in the locked attached garage when the laundry room is located. The centrally stored medication is located in a locked closet. A laundry area along with detergent are observed in the locked attached garage. LPA observed a sufficient supply of food and water present. Emergency supplies, water and rations are also stored in the attached garage. LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. Administrator certificates on display are shown to be outdated but current versions are in the facility file. A Technical Advisory is issued regarding documentation requirements. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KATHRYN JANE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 306001851
	VISIT DATE: 09/12/2022

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CONTINUED FROM FORM LIC809

Fire extinguishers present are charged and have up-to-date maintenance shown on the attached tags.

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a patio umbrella are present for the enjoyment of residents and visitors. The perimeter gats on is 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. A Technical Advisory is issued regarding the required administrator certificate posting. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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