<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003462
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:25:57 PM


Document Has Been Signed on 09/29/2022 02:25 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:OLIVERA RESIDENTIAL HOMEFACILITY NUMBER:
306003462
ADMINISTRATOR:REYNALDO BALOFACILITY TYPE:
740
ADDRESS:24111 OLIVERA DRIVETELEPHONE:
(949) 460-0583
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 3DATE:
09/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Reynaldo Balo, AdministratorTIME COMPLETED:
02:30 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 Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of a Plan of Correction (POC) visit, based on the deficiency cited in LIC form 809D on 07/19/2022. LPA was greeted and granted entry into the facility by Administrator Reynaldo Balo and explained the reason for the visit.

LPA was able to observe that the medication is stored securely in a closet equipped with a digital lock.

As of 09/29/2022, the deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally stored medicines is cleared. Licensee has secured the medication.

Licensee has complied with the terms of the Plan of Corrections.

LPA observed the administrator certificate on display has expired. Administrator provided LPA with documentation of the completed training ahead of the July 2021 renewal date. A copy of the administrator certificate will be submitted by Administrator shortly.

LPA Saborit-Guasch conducted an exit interview with facility representative and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 1