<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002241
Report Date: 06/18/2024
Date Signed: 06/20/2024 02:05:09 PM


Document Has Been Signed on 06/20/2024 02:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HARBOR VIEW ESTATEFACILITY NUMBER:
306002241
ADMINISTRATOR:VILMA B. MANUELFACILITY TYPE:
740
ADDRESS:3911 CALLE MAYOTELEPHONE:
(949) 661-6874
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Vilma Manuel, AdministratorTIME COMPLETED:
11:50 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
Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Vilma Manuel, Administrator.

The facility is a single story building with an approved fire clearance of six non-ambulatory residents of which six are approved for hospice. The facility currently has a census of five residents in care with two on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 111.0 and 111.3 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on April 24, 2024. The facility’s last fire drill was conducted on April 30, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed three of three staff training and fingerprint records. LPA conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a pending renewal administrator certificate which will expire on March 9, 2026. Administrator has proof of certified mail and check was cashed.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Vilma Manuel, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1