306003460-9-27-2024-22-AS-ARJR-D9HNSE-20240927104302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003460
Report Date: 09/27/2024
Date Signed: 09/27/2024 10:43:06 AM

Document Has Been Signed on 09/27/2024 10:43 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BASIA RESIDENTIAL CARE		FACILITY NUMBER:	306003460
ADMINISTRATOR/ DIRECTOR:	BARBARA MANCZYK		FACILITY TYPE:	740
ADDRESS:	23931 GOWDY AVENUE		TELEPHONE:	(949) 768-0452
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Joanna Manczyk-Administrator, Barbara Manczyk-Administrator		TIME VISIT/ INSPECTION COMPLETED:	10:58 AM

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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Administrator (AD) Joanna Manczyk.

For today’s visit, LPAs observed a total of four residents in care and two staff members on duty.

LPAs observed the Administrator's Certificate for facility AD Barbara Manczyk which expires on November 11, 2025.

LPAs toured the interior and exterior portions of the facility with AD Manczyk. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of five bedrooms, of which four are resident bedrooms, and one is a bedroom for staff. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three full restrooms and three half restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.2-111.0 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located by the kitchen.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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: BASIA RESIDENTIAL CARE	FACILITY NUMBER: 306003460
	VISIT DATE: 09/27/2024

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LPAs observed the emergency disaster and evacuation plan which is located by Residents' bedroom hallway/activities closet. Facility had back-up emergency food and water supply. LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

During today's visit LPAs observed residents doing their morning stretching exercises.

LPAs reviewed four resident and three staff files. LPAs interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised AD Manczyk to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Manczyk.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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