306003820-12-6-2022-22-AS-JHAY-CLUS7T-20221206123804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003820
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:38:13 PM

Document Has Been Signed on 12/06/2022 12:38 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:	ADRIANA ELDERLY CARE HOME I		FACILITY NUMBER:	306003820
ADMINISTRATOR:	MENDOZA, RICHARD		FACILITY TYPE:	740
ADDRESS:	25342 ADRIANA STREET		TELEPHONE:	(949) 859-9894
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	12/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Kevin Mendoza		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called Administrator (AD) Kevin Mendoza via telephone who arrived and was present for the visit.

Administrator Adriana Mendoza has a current Administrators Certificate that expires 04/06/23. There were six residents present during the visit.

At 10:20 AM LPA Haley and staff began the inspection at the entrance of the facility. A screening station with hand sanitizer, face mask and screening logs was observed right next to the front door. A temperature thermometer was mounted in the wall. Next to the screening station LPA observed a locked medication cabinet. In the locked medication closet LPA observed a first aid kit hanging on the wall.

Resident bedrooms were clean, organized, and had all necessary requirements. Resident bathrooms were clean, organized, and grab bars were present in the showers and near the toilet in each resident bathroom. In the hallway cabinets near the resident rooms, LPA observed plenty of clean linen and towels.

The kitchen area was observed. Knives and sharp objects are locked in a drawer near the sink. All burners on the stove were operational. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items.LPA Haley advised AD Mendoza on the importance of having enough food in the facility at all times. AD Mendoza stated the facility goes to the grocery store on Thursday. A fully charged fire extinguisher was mounted on the wall next to the pantry. In the dining room, LPA observed a piano, board games for the residents, and some exercise pedals for the residents to enjoy.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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: ADRIANA ELDERLY CARE HOME I	FACILITY NUMBER: 306003820
	VISIT DATE: 12/06/2022

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The backyard had clear walkways, free of tripping hazards. Both side exit gates were self closing and self latching. LPA Haley observed tables with sun shades, and chairs. LPA Haley observed a few items near the side exit gate that are no longer being used and need to disposed of. The items consist of some old blinds, an old commode, and an old table sun shade.

In the garage LPA Haley observed a washer and dryer in the garage. There's a locked cabinet used to store soaps and detergents right next to the washer and dryer. In the center of the garage LPA observed several items bing stored. Observed were the following items: Wheelchair, walker, commode, exercise peddler, step stool, hoyer lift, chairs, mattress, pillows, clothing, and several boxes of adult diapers.

LPA Haley advised AD Mendoza on the importance of getting rid of items no longer being used and keeping the garage and backyard free of clutter and debris at all time. An LIC9102 Advisory Notes: Technical Violation was issued for the clutter and debris observed.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report and LIC9102s was provided to Administrator Mendoza.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

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