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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003492
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:18:29 PM


Document Has Been Signed on 07/27/2022 04:18 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:CASTILLA LANE VILLAFACILITY NUMBER:
306003492
ADMINISTRATOR:DIZON, EMMANUELFACILITY TYPE:
740
ADDRESS:24272 CASTILLA LANETELEPHONE:
(949) 716-8779
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 2DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. Via phone, LPA spoke with Administrator Sherry Dizon and stated the purpose of this visit.

This facility is a single level structure and licensed for 6 non-ambulatory and with hospice waiver for 6. For this visit there was one resident under hospice care. After completing the Coronavirus 2019 (COVID 19) screening procedure, LPA Marin was granted entry in the facility. LPA observed two residents in care, one staff on the floor, and one off duty staff staying in the staff room. LPA toured the interior and exterior portions of the facility. There were six private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and water fixtures in good repair. Hot water was measured at 120 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non- perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self latching. LPA reviewed the infection control plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Administrator's certificate for Sherry Dizon id valid until November 26, 2023. LPA also informed AD to send all incident reports and general correspondence to CCLASCPOrangeCountyRO@dss.ca.gov.

No citation was issued for this visit.

LPA Marin conducted a phone exit interview with AD S. Dizon. AD gave permission for staff to sign and receive the report. LPA left copy of this report and California Department of Public Health flyers on vaccination recommendations for COVID 19.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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