306003774-7-13-2022-22-AS-CDPO-CGAU3L-20220713151344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003774
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:13:53 PM

Document Has Been Signed on 07/13/2022 03:13 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:	JUST LIKE HOME, III		FACILITY NUMBER:	306003774
ADMINISTRATOR:	ROBERT MASSUCO		FACILITY TYPE:	740
ADDRESS:	782 S. FAIRMONT WAY		TELEPHONE:	(714) 602-6231
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 5	DATE:	07/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:53 PM
MET WITH:	Administrator - Robert Massuco		TIME COMPLETED:	03:42 PM

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	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature upon entry. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Roda Paderna about visit. As of 7/13/22, there are a total of 4 active COVID-19 cases (3 residents, 1 staff (on duty)) in the facility that AD verbally reported during beginning of visit. LPA De Perio informed AD about needing to complete the COVID Script, and AD agreed to complete it and submit it by 7/14/22. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Robert Massuco which expires on 3/29/24 and the Administrator’s certificate for Roda Paderna which expires on 11/29/22. LPA De Perio toured the interior and exterior portions of the facility with AD Paderna. The facility is a single level structure and is licensed for 6 residents. Currently, there are a total of 5 residents in care, of which two are on hospice. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 111.5 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Fire extinguisher was charged, mounted and located in the kitchen. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is one exit gate in the backyard, which was self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway. Facility had back-up emergency food and water supply, located in the kitchen.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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: JUST LIKE HOME, III	FACILITY NUMBER: 306003774
	VISIT DATE: 07/13/2022

NARRATIVE

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LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located next to the medication cabinet. Medications were locked in a cabinet and inaccessible to resident. Toxins were also observed to located in the laundry room and were observed to be locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Paderna. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service 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 today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assign LPA.

LPA De Perio conducted an exit interview with AD Paderna and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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