306002429-9-19-2024-22-AS-KSGH-D99QUZ-20240919122934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002429
Report Date: 09/19/2024
Date Signed: 09/19/2024 12:31:58 PM

Document Has Been Signed on 09/19/2024 12:31 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 - PEPITA HOME		FACILITY NUMBER:	306002429
ADMINISTRATOR:	RUSSELL VENANZI		FACILITY TYPE:	740
ADDRESS:	26741 PEPITA DRIVE		TELEPHONE:	(949) 589-0145
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Russell Venanzi, Assistant Administrator Tommy Tran, Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and William Vanegas made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by facility caregiver. LPAs met with Administrators (AD) Tommy Tran and Russell Venanzi and explained the purpose of the inspection. LPA reviewed list of Guardian roster for facility. Facility association for one caregiver had been submitted to the Department on September 4, 2024 and had not been processed. LPAs proceeded to update the staff member’s association in Guardian during the visit. During the inspection, LPAs and AD conducted a tour of the inside and outside of the facility, common living areas, resident rooms, kitchen, garage and observed the following: This is a one-story home with four resident bedrooms, two shared resident rooms, and two single resident rooms, and one staff bedroom, two bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in the living room, and a volunteer playing the piano for residents. Residents were also observed resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 105.0 degrees Fahrenheit. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents in the bathroom and laundry area. Medication cabinet was observed to be locked and inaccessible to residents. 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: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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 - PEPITA HOME	FACILITY NUMBER: 306002429
	VISIT DATE: 09/19/2024

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CONTINUED FROM FORM LIC809

LPAs reviewed six resident files and four staff files. Staff files contained documentation for initial staff training and staff training conducted in the past year, criminal background clearance, health screening, and personnel files for all staff members. Residents files contained a physician’s report, admission agreement, needs assessment, I.D, property and valuables documentation, and consent forms for all residents. LPAs interviewed three residents and three staff.

During the visit, LPAs provided a Technical Assistance Advisory Note for the reappraisal requirements for residents with dementia as well as a Technical Assistance Advisory Note for the documentation requirements for fire drills. Based on the observations made during the visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. 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: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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