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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003774
Report Date: 07/06/2021
Date Signed: 07/06/2021 03:57:53 PM

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, IIIFACILITY NUMBER:
306003774
ADMINISTRATOR:ROBERT MASSUCOFACILITY TYPE:
740
ADDRESS:782 S. FAIRMONT WAYTELEPHONE:
(714) 602-6231
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 4DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rhoda PadernaTIME COMPLETED:
03:20 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 Administrator Rhoda Paderna and explained the reason for the visit.

At 1:45 PM, LPA toured the facility with Administrator Paderna. Facility has 4 residents in care during today's visit. LPA observed residents relaxing in their rooms. 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. Hand washing signs are posted throughout the facility. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Administrator Paderna has an administrator certificate expiring on 11/29/2022. Facility has completed the mitigation plan. LPA observed emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded 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 all required documentation including emergency information.

LPA consulted with Administrator regarding the importance of ensuring all auditory exit alarms are on and operational as well as ensuring an ample supply of emergency food and water.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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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