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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003564
Report Date: 09/14/2022
Date Signed: 09/15/2022 06:50:00 AM


Document Has Been Signed on 09/15/2022 06:50 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:JUST LIKE HOME IIFACILITY NUMBER:
306003564
ADMINISTRATOR:ROBERT MASSUCOFACILITY TYPE:
740
ADDRESS:10265 SHERWOOD CIRCLETELEPHONE:
(714) 532-4405
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 5DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Fernando YusiTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Fernando Yusi and explained the reason for the visit. Caregiver Alicia Lira was present as well. Administrator Rhoda Paderna arrived during the visit.

At 10:40 AM, LPA toured the facility with Administrator Paderna. Facility has five residents in care during today's visit with three on hospice care. LPA observed residents relaxing in their rooms or common areas. All residents appeared well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. Hand washing signs are posted throughout the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. Administrator Robert Massuco has an administrator certificate expiring on 03/29/2024. LPA toured the kitchen and observed ample food supply. Facility has completed the mitigation and infection control plan. LPA observed ample emergency food and water as well as the first aid kit which contained all required items. Smoke detectors tested operational during today's visit. LPA toured the outside grounds and observed the outside visitation area. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed select files which contained required documentation including emergency information.


Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. Exit conducted and a copy of this report was left with administrator.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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