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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003823
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:27:06 AM


Document Has Been Signed on 11/04/2022 09:27 AM - 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 IVFACILITY NUMBER:
306003823
ADMINISTRATOR:MENDOZA, ADRIANAFACILITY TYPE:
740
ADDRESS:24851 ARGUS DRIVETELEPHONE:
(949) 600-5734
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Facility Administrator - Richard MendozaTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 10/14/2022. LPA De Perio explained reason for visit and was greeted by staff on duty, who contacted facility administrator (AD) Richard Mendoza about visit.

For today's visit, LPA De Perio verified that there are currently 4 residents in care, and 2 staff on duty.

On 10/14/2022, licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA De Perio observed cleaning supplies and disinfectants stored in an unlocked cabinet located in the laundry room, of which the laundry room is unlocked at all times. This poses an immediate health, safety or personal rights risk to persons in care.

*Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Space has been CLEARED. Licensee has secured noted items and now has a designated locked location for disinfectants, cleaning solutions, poisons, and other items. Licensee has complied with the terms of the POC.

For this visit, no deficiencies were issued at this time. No citations issued at this time.

LPA De Perio conducted an exit interview with AD Mendoza and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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