306003560-9-16-2022-22-AS-KSGH-CJBNNK-20220916103651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003560
Report Date: 09/16/2022
Date Signed: 09/16/2022 10:37:05 AM

Document Has Been Signed on 09/16/2022 10:37 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GRANNY'S PLACE IV		FACILITY NUMBER:	306003560
ADMINISTRATOR:	SIMPSON, RONALD		FACILITY TYPE:	740
ADDRESS:	25665 SABINA AVENUE		TELEPHONE:	(949) 855-0120
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ronald Simpson, Licensee Dianna Manalo, Administrator		TIME COMPLETED:	10:50 AM

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	On 09/16/2022 at 9:00am, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Alvaro Ramirez made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPAs were greeted and granted entry by Norma Elayda, caregiver and explained the purpose of the visit. Facility licensee Ronald Simpson and administrator Dianna Manalo were notified by telephone and arriver later to assist with the visit. At approximately 9:30am, LPA accompanied by caregiver and administrator toured the physical plant of the facility. There are currently six (6) residents in care, three (3) of which are receiving hospice care. Residents are observed relaxing in the common area or in their respective bedrooms and appear clean and well taken care of. The six individual bedrooms include all necessary components, with the exception of one bedroom with no reading light. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept in a locked drawer in the kitchen secured by a functional magnetic lock. Cleaning supplies are stored securely under lock in the attached garage as well as under the kitchen sink. The centrally stored medication is located in a locked cabinet with a magnetic lock. A 30-day supply of medication is observed, along with pre-poured medication clearly identified and labelled by resident and time of administration. LPA observed a sufficient supply of food and water present. LPA observed the facility has COVID-19 Precautions posters and all required department postings. One outdated administrator certificate is observed for administrator Dianna Manalo but will be updated. Staff present is adequately cleared and associated in Guardian. Fire extinguisher present is charged and has up-to-date maintenance shown on the attached tags. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRANNY'S PLACE IV	FACILITY NUMBER: 306003560
	VISIT DATE: 09/16/2022

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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a table with an umbrella are present for the enjoyment of residents and visitors. The perimeter gates on both sides of the facility are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is issued regarding the furninshing requirements as well as postural supports observed during the visit. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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