306003821-12-11-2024-22-AS-RMAZ-DBV2RZ-20241211163822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003821
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:38:27 PM

Document Has Been Signed on 12/11/2024 04:38 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ADRIANA ELDERLY CARE HOME II		FACILITY NUMBER:	306003821
ADMINISTRATOR/ DIRECTOR:	MENDOZA, RICHARD		FACILITY TYPE:	740
ADDRESS:	25351 ADRIANA STREET		TELEPHONE:	(949) 600-5738
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Richard Menoza		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 Analysts (LPAs) Ruth Martinez and Nancy Guillen is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff and LPAs explained the nature of the visit. Richard Mendoza and Kevin Mendoza Administrators arrived shortly after and met with LPAs. There are four residents at the facility and there are one resident receiving hospice services currently. LPA accompanied by the Administrators began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage in two spare refrigerators located in back patio and additional non-perishables stored in garage storage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in the living room. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom. LPA measured the hot water temperature which measured 115.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of Continued on LIC809-C

Armando J Lucero	TELEPHONE: (949) 430-1222
Ruth Martinez	TELEPHONE: (657) 285-1397
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADRIANA ELDERLY CARE HOME II	FACILITY NUMBER: 306003821
	VISIT DATE: 12/11/2024

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
26
27
28
29
30
31
32

obstructions. LPA observed there are seating areas for residents’ enjoyment. LPA observed a swimming pool adjacent to the house with a fence enclosing the whole pool. LPA observed the pool gate has one entry door which opens away from the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed a fire extinguisher with service date March 13, 2024, in the entry way of the kitchen. Fire drills are conducted every three months. LPA Guillen began review of records. LPA reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. Technical Advisories are being issued.

This report was reviewed with the Administrators and a copy of this report was provided to the facility. The Technical Advisories were provided at the end of the visit.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2