306003821-12-6-2022-22-AS-JHAY-CLUU4K-20221206141516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003821
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:15:24 PM

Document Has Been Signed on 12/06/2022 02:15 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 II		FACILITY NUMBER:	306003821
ADMINISTRATOR:	MENDOZA, RICHARD		FACILITY TYPE:	740
ADDRESS:	25351 ADRIANA STREET		TELEPHONE:	(949) 600-5738
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	12/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Kevin Mendoza		TIME COMPLETED:	02:15 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 five residents present during the visit.

At 01:00 PM 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 near the front door. Next to the screening station LPA observed a locked staff bedroom.

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 bathroom #1 hot water was measured at 120.0 degrees Fahrenheit and 118.7 degrees Fahrenheit in bathroom #2. Clean linen was observed in a hallway cabinet outside the resident rooms. On the other side of the facility LPA observed a locked hallway closet near the resident rooms used to store medications.

The living room area was clean and neatly organized. A TV, reclining chairs, and a table was observed.

The kitchen area was clean and organized. Knives and sharp objects are locked in a drawer near the refrigerator. 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. A fully charged fire extinguisher was mounted on the wall at the entrance of the facility.

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 II	FACILITY NUMBER: 306003821
	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 a pool surrounded by a gate that meets regulation requirements. Tables with sun shades, and chairs was observed in the backyard. LPA observed a two piles of rock debris near the rear fence in the backyard. LPA Haley advised AD Mendoza on the importance of keeping the facility free of clutter at all times.

The garage was used to store miscellaneous facility items. LPA Haley observed a washer and dryer in the garage. Next to the washer and dryer LPA observed a locked tool box with detergents, soaps, and bleach. In the center of the garage LPA observed several items bing stored. Some of the items observed were: wheelchairs, walker, commodes, dressers, 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.

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 LIC9102 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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