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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002455
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:50:20 PM

Document Has Been Signed on 05/26/2022 04:50 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:INDEPENDENT OPTIONS INC/ANACAPA HOUSEFACILITY NUMBER:
306002455
ADMINISTRATOR:BUTCH MALLILLINFACILITY TYPE:
735
ADDRESS:2538 ANACAPA DRIVE #105TELEPHONE:
(714) 556-2591
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Paula AvilaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the required annual inspection focusing on the Infection Control. LPA was greeted and granted entry by Caregiver Paula Avila after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and toured the interior and exterior portions of the facility. Upon entry, LPA observed the screening station and one COVID-19 poster on the front door. Administrator (Admin) Butch (Alvin) Mallillin assisted with the tour around 3:00 pm.

Around 2:50 pm, LPA toured the facility with Caregiver Avila and Admin joined the tour upon arrival. The facility is a single level structure and licensed for four clients of which two are non-ambulatory. The facility offers a Level 4 service. As of today, there were four clients residing in the facility. LPA observed one staff on duty and four clients relaxing in their respective bedrooms. LPA observed one department posting on the front door but throughout the facility due to the clients removing the posters. A hand washing sign was observed in one out of the four bathrooms as the remaining three clients tend to remove the posting. LPA observed all restrooms had ample soap/sanitizer but appeared unclean. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Clients' bedrooms appeared clean and sanitary and had all required components. Smoke detectors and carbon monoxide tested operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medication and sharp items were inaccessible to the clients in care, and the fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture under a lattice with ample shading. LPA observed the emergency disaster and evacuation plans. Facility does have a back-up emergency food, water supply, and 30 day supply of PPEs. The First Aid Kit met all the required components.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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: INDEPENDENT OPTIONS INC/ANACAPA HOUSE
FACILITY NUMBER: 306002455
VISIT DATE: 05/26/2022
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LPA consulted the following: to post additional COVID-19 precautionary signs on the front door, to repair the four auditory exit alarms, to add one auditory exit alarm on the exit door in Bedroom #4 and the backyard gate, to deep clean the rust and stains in all four bathrooms, and to update the Emergency Disaster Plan for Adult Day Programs (LIC610D).

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. All the clients have access to a tablet provided by the facility.



LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the Administrator will follow-up with the corrections. An exit interview was conducted with Administrator Butch (Alvin) Mallillin, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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