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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003462
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:30:31 PM


Document Has Been Signed on 07/12/2024 02:30 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
ORANGE COUNTY RO, 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: 5DATE:
07/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Reynaldo Balo, AdministratorTIME COMPLETED:
03:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a Plan of Corrections visit following multiple type A citations issued during the facility's annual visit conducted on July 2, 2024. LPA was greeted and granted entry by administrator Reynaldo Balo and explained the purpose of the visit.

LPA accompanied by administrator conducted a tour of the physical plant. One additional staff member was observed to be present and working and was confirmed to be cleared and associated in Guardian to the present licensed location. No other individuals present besides the five currently admitted residents. Proof of hire for an additional staff member was also provided by administrator, however the staff member in question is not yet being scheduled as their background clearance still shows as "In Process" in Guardian.

The facility's liability insurance contract is currently stated to be with an underwriter for the purpose of issuing a quote. Administrator followed up on the progress with LPA throughout the process, therefore no citations for failure to correct were issued at this time.

LPA provided additional consultation on the potential scheduling of an informal meeting at the Adult & Senior Care Program Orange County Regional Office as well as provided information to the administrator and licensee on the Department's Technical Support Program (TSP). Administrator agreed to have a referral submitted on his behalf. Administrator additionally stated that the rest of the plan of corrections was in progress, including but not limited to staff records and training as well as resident records. A Technical Violation Advisory Note was also issued on the proper disposal of needles and syringes.

An exit interview was provided and a copy of this report and two clearance letters were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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