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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002428
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:21:57 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/19/2022 11:21 AM - 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:FAMILY CARE - EL MAR HOMEFACILITY NUMBER:
306002428
ADMINISTRATOR:VENANZI, RUSSELLFACILITY TYPE:
740
ADDRESS:26542 EL MAR DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brylee Tesnado, caregiver
Janet Martinez, caregiver
Russel Venanzi, Administrator (by telephone)		TIME COMPLETED:
11:30 AM
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On 08/19/2022 at 9:45am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by caregivers Brian Tesnado and Janet Martinez after explaining the purpose of the visit. Administrator and licensee Russell Venanzi was notified and spoke with LPA at the beginning of the visit and to review the final report before authorizing facility staff to sign.

At approximately 10:05am, LPA accompanied by caregiver toured the physical plant of the facility. There are currently three (3) residents in care. The residents are observed relaxing in the common areas and appear clean and well taken care of. The four (4) bedrooms include all necessary components. An ample supply of linen is observed. The two (2) shared bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Full rails are observed on a hospital bed in resident R1 bedroom. Caregiver states that resident is not currently on hospice but is diagnosed with Huntington's Disease. LPA discussed the situation with facility administrator and reviewed the resident files that shows extensive history of hospice care. There is also documentation of past granted exceptions for this resident in the context of their diagnosed degenerative disease.

Sharp instruments are stored in a kitchen drawer secured by a key lock. The centrally stored medication and resident files are located in a locked closet off of the main living area. LPA observed a sufficient supply of food and water present. Cleaning supplies are located in a locked cabinet under the kitchen sink, secured by a key lock.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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 2
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: FAMILY CARE - EL MAR HOME
FACILITY NUMBER: 306002428
VISIT DATE: 08/19/2022
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CONTINUED FROM FORM LIC809-C

Staff present is correctly cleared and fingerprinted. Staff association for caregiver Janet Martinez was submitted to the Department on 08/16/2022. Caregiver already appears in Guardian under other facilities.

LPA and caregiver toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area is present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water 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 in regards to requirements for updated Physician Reports for dementia residents. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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