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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003713
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:48:27 PM

Document Has Been Signed on 04/28/2022 02:48 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:LERIZA'S GUEST HOMEFACILITY NUMBER:
306003713
ADMINISTRATOR:MARIZA OLIVAFACILITY TYPE:
740
ADDRESS:4019 VIA MANZANATELEPHONE:
(949) 240-0613
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 5DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Mariza Oliva and Dulce FernandezTIME COMPLETED:
10:20 AM
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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 and explained the reason for the visit. Administrator Mariza Oliva arrived during the visit. Mariza Oliva has an administrator certificate expiring on 05/04/2022.

At 8:32 AM, LPA toured the facility with Caregiver Dulce Fernandez. Facility has 5 residents in care during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet/ questionnaire. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility mitigation plan has been submitted and is pending review. LPA observed an ample supply of emergency food and water. LPA observed the shaded outside visitation area. Exit gates are self latching and unlocked. LPA observed the locked medication area. Facility does not utilize a medication administration record however medications are audited weekly. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files have updated emergency information as well as required documents. All residents and staff are vaccinated for Covid-19.

LPA consulted with Administrator regarding the importance of posting the Emergency Disaster Plan, LIC 610E, in entrance of facility.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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