306002428-9-11-2024-22-AS-KSGH-D8ZS9K-20240911134051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002428
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:41:11 PM

Document Has Been Signed on 09/11/2024 01:41 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:	FAMILY CARE - EL MAR HOME		FACILITY NUMBER:	306002428
ADMINISTRATOR:	VENANZI, RUSSELL		FACILITY TYPE:	740
ADDRESS:	26542 EL MAR DRIVE		TELEPHONE:	(949) 589-0145
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Russell Venanzi, Administrator Tommy Tran, Assistant Administrator		TIME COMPLETED:	01:00 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Facility administrator Russell Venanzi was notified of the visit via telephone. Assistant administrator Tommy Tran arrived later to assist with the visit. Administrator Venanzi also assisted in person later. During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a two-story home with three private and one shared bedrooms in addition to the facility's common living areas. Second level is only for use by overnight staff. There are two bathrooms, one shared, one en-suite from the shared bedroom, both of which observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. One bed is observed to be equipped with full rails for postural support as well as a variable pressure bed. This specific resident is confirmed to be receiving hospice care that was initiated on July 30, 2024. Plan of care provided and reviewed during the visit. There are currently five residents admitted to the facility, one of which is receiving hospice care. There are no bedridden residents admitted at the time of the visit. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire and emergency drills have been conducted quarterly and documented. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance tag. There is adequately shaded outside space with outdoor furniture present. There is a self-latching gate on one side. The route of egress is free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FAMILY CARE - EL MAR HOME	FACILITY NUMBER: 306002428
	VISIT DATE: 09/11/2024

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CONTINUED FROM FORM LIC809
Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed five resident files and three staff files. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. Current CPR training, training documentation and health screenings on file. Two resident and two staff interviews were conducted during the visit.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three Technical Assistance advisory notes are provided with a consultation on the required Infection Control Plan, dimensions of the Residential Care Facility for the Elderly Complaint poster PUB 475 as well as the contact information list needed in the Emergency and Disaster Plan . An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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