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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003460
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:47:13 PM

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:BASIA RESIDENTIAL CAREFACILITY NUMBER:
306003460
ADMINISTRATOR:BARBARA MANCZYKFACILITY TYPE:
740
ADDRESS:23931 GOWDY AVENUETELEPHONE:
(949) 768-0452
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Joanna ManczykTIME COMPLETED:
04:50 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Norman Woodridge for the purpose of conducting an Covid-19 Annual Inspection. LPA met with Administrator (AD) Joanna Manczyk and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA observed the following:

There were 4 residents present at the facility and residents were doing well. Resident rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hallways and walkways that were free of obstruction. LPA observed Covid-19 related training logs and certificates for staff. LPA and administrator discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPA also discussed Covid-19 Mitigation Plan. A copy of PIN 21-38-ASC was given administrator.

No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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