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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002987
Report Date: 09/26/2022
Date Signed: 09/28/2022 05:36:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/28/2022 05:36 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:MISSION VIEJO CARE COTTAGES 2FACILITY NUMBER:
306002987
ADMINISTRATOR:MIGUELITO "BING" FAJARDOFACILITY TYPE:
740
ADDRESS:24142 DELPHI STREETTELEPHONE:
(949) 297-8948
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Miguelito Fajardo, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/19/2022 at 11:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregiver Miriam Blanca and explained the purpose of the visit. Administrator Miguelito Fajardo was notified by phone and arrived later to assist with the visit.

At approximately 12:10pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently five (5) residents in care, one (1) of which is receiving hospice care. Residents are observed relaxing in the facility's common areas or in their respective bedrooms. All appear clean and well taken care of. The four individual and one shared bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are kept in a locked drawer in the kitchen. Cleaning supplies are located in a cabinet under the sink with a child-proof lock and in other cupboards in the locked laundry area. The centrally stored medication is located in a locked closet next to the entrance door. LPA observed a sufficient supply of food and water present. Emergency water and rations are also stored in the attached garage. The facility has an ample supply of linen available for use by residents.

LPA observed the facility has COVID-19 Precautions posters and all required department postings along with hand washing signs. The fire extinguishers present are charged and have up-to-date maintenance shown on the attached tag.The regular caregivers S1 and S2 called out due to a family emergency. Administrator had to make last minute adjustments and hire relieving caregivers on short notice. One of the two caregivers (S3) present is adequately cleared in Guardian but is not associated to the facility. Another caregiver present (S4) is not currently background checked in the state of California and has only previously worked in Arizona. Caregiver is not associated to the facility either.
CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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 4


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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987
VISIT DATE: 09/26/2022
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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and an umbrella for shade are present in the backyard for the enjoyment of residents and visitors. The perimeter gates on both sides of the facility are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory regarding staff associations is being issued. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/28/2022 05:36 PM - It Cannot Be Edited

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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review (...) shall prior to working (...) in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Based on observation, record review and interviews, staff member S3 was not fingerprint cleared prior to working which poses an immediate Health, Safety, or Personal Rights risk to persons in care. CIVIL PENALTY ASSESSED.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 09/28/2022 05:36 PM - It Cannot Be Edited

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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited

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CCR Section 87608(3) on Postural Supports indicates that (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
This requirement is not met as evidenced by:
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Based on observation and record review, licensee was not able to provide the requested documentation during the visit which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4