<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003945
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:41:06 PM


Document Has Been Signed on 07/29/2022 02:41 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:MIMI'S GUEST HOMEFACILITY NUMBER:
306003945
ADMINISTRATOR:MINERVA ROMEROFACILITY TYPE:
740
ADDRESS:333 CALLE ESCUELATELEPHONE:
(949) 293-3097
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:5CENSUS: 3DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Mimi Romero and Luisa GonzalezTIME COMPLETED:
11:40 AM
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) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Luisa Gonzalez and explained the reason for the visit. Administrator Mimi Romero arrived during the visit. LPA confirmed that Administrator Romero has a current administrator certificate expiring on 07/31/2023.

At 10:29 AM, LPA toured the facility with Administrator Romero. Facility has 3 residents in care during today's visit, with 2 residents on hospice care. Facility has bedridden fire clearance for one resident. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms are single occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet and LPA was screened upon entry. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. Smoke detector/ carbon monoxide detectors are hardwired and tested operational during today's visit. LPA toured the outside grounds and observed multiple shaded outside visitation areas as well as a secured pool. Exit gate is unlocked. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed three resident files during the visit and all files reviewed are up to date including emergency information. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator on the importance of taking staff and resident temperatures daily and documenting as well as having an ample supply of N95 masks on-site at all times. Additionally, Administrator to ensure hand-washing signs are posted in all facility restrooms.
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 1