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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003697
Report Date: 05/06/2022
Date Signed: 05/06/2022 09:50:06 AM

Document Has Been Signed on 05/06/2022 09:50 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:MIRADA MANOR/GREENLEAFFACILITY NUMBER:
306003697
ADMINISTRATOR:ROBERT TALENSFACILITY TYPE:
735
ADDRESS:8616 GREENLEAF STREETTELEPHONE:
(714) 458-8888
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jared Merjanio, Mirasol Ebuenga, Delia Alsobrook, Robert TalensTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Jared Mejanio, Mirasol Ebuenga, Delia Alsobrook and stated the purpose of this visit. Administrator Robert Talens arrived during the visit at 8:35 AM and provided assistance.

The facility is a single level structure and licensed for six ambulatory. This facility offers a Level IV A & D service.

About 8:00 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed six clients in care and three staff members on the duty. LPA toured the interior and exterior portions of the facility. There were six private client rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide alarms were tested to be operational. Bathroom (1) was observed to be in good repair and hot water was measured at 114.6 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 113.3 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA noticed a ladder and gardening tools were observed and asked Administrator remove items so residents could not access them. Garage was mainly used as a storage with an operational washer/dryer and emergency clothes and supplies. First aid kits were kept locked. Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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: MIRADA MANOR/GREENLEAF
FACILITY NUMBER: 306003697
VISIT DATE: 05/06/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult 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.

For this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Robert Talen and copy of this report was explained and left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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