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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004247
Report Date: 08/19/2021
Date Signed: 08/19/2021 01:41:40 PM

Document Has Been Signed on 08/19/2021 01:41 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:VENTANA ARF - LA SIERRAFACILITY NUMBER:
306004247
ADMINISTRATOR:HECTOR OBARFACILITY TYPE:
735
ADDRESS:26911 LA SIERRA DRTELEPHONE:
(949) 916-0084
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Bryan Pelayo, House ManagerTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility was greeted and granted entry by facilities house manager Bryan Pelayo. LPA explained the nature of the visit with house manager.

LPA Martinez accompanied by house manager toured the facility. There are three clients in care and no active covid-19 cases in facility. LPA observed three clients in living room watching a movie. All clients appeared clean and well taken care of. LPA observed required department postings in the facility. All restrooms observed to have soap/sanitizer and appeared to be clean. Clients bedrooms are all private and appeared to be clean and sanitary with all required components. Facility is taking covid-19 precautionary measures daily. LPA observed a check in station with sanitary precaution in the main entry of the facility. LPA observed the emergency disaster and evaluation plan. LPA observed food, water as well as first aid kits in the facility. Facility has a supply of PPE, incontinence, and cleaning supplies. Facility has completed the LIC808 Mitigation plan and LPA Martinez reviewed/approved the plan on site. LPA will supply approved copy to Administrator via email for records keeping at the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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