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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004247
Report Date: 08/30/2024
Date Signed: 08/30/2024 11:56:15 AM

Document Has Been Signed on 08/30/2024 11:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VENTANA ARF - LA SIERRAFACILITY NUMBER:
306004247
ADMINISTRATOR/
DIRECTOR:		HECTOR OBARFACILITY TYPE:
735
ADDRESS:26911 LA SIERRA DRTELEPHONE:
(949) 916-0084
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Hector Obar- Administrator
Dempsey Nicolas- House Manager/Care Staff		TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year evaluation using the Care Inspection Tool. LPA Cho was greeted and granted entry by House Manager (HM) Dempsey Nicolas and explained the nature of the visit. Administrator (Admin) Hector Obar arrived on premise shortly after.

The facility is a two story property located in a residential neighborhood. Facility is licensed to serve six (6) clients of which two (2) may be non-ambulatory. There are two clients in care during today's visit with two care staff on duty.

LPA toured the interior and exterior portion of the facility and observed the facility to be clean, sanitary, and operational. The first floor consists of four bedrooms occupied by two clients and one staff. Two client bathrooms are also on the first floor. The clients' bedrooms were appropriately furnished and in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed, and clean linens were adequately stocked. Bathrooms were food to be in compliance, clean, and operational. The water temperature measured at 116.9 and 117.3 degrees Fahrenheit. The second floor consists of three rooms and one bath which is occupied by the second staff. LPA observed the evacuation chair stored in a closet by the stairwell. The fireplace was screened. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two day supply of perishables and seven day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. The exit gate was operating. The swimming pool gate was at least 5 feet high and the gate latch self-closes and self-latches. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers which were mounted, charged, and serviced on June 11, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational on two floors. LPA observed the emergency disaster supplies including food/water in the living room closet.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 11:56 AM - It Cannot Be Edited


Created By: Jessica Cho On 08/30/2024 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one out of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee to submit a copy of the health screening for S2 to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247
VISIT DATE: 08/30/2024
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The emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements. A working telephone number, (949) 916-0084, was dialed and remains available. Completion of course work for the Administrator's certification was verified and is pending approval. The balance of the annual licensing fee in the amount of $1,135.00 was paid in full during today's visit.

LPA conducted an audit of two client files and two personnel files. Facility did not maintain a medical assessment for one out of two staff. Staff and client interviews were attempted and conducted for one client and two staff. Medications were audited for two clients. No discrepancies were observed. Additionally, there were no concerns with the Personal & Incidental (P&I) funds. Remaining cash matched the balance on the ledger. Admin was advised on the following: to document the starting balance on the ledger for the clients' source of income effective September 1, 2024 and to update the Emergency Disaster Plan (LIC610D) using the current template revised on 12/21.

Based on the observations made during today's visit, a deficiency is being cited as per the Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC809-D. Two Advisory Notes are being issued.

An exit interview was conducted with Administrator Hector Obar and House Manager Dempsey Nicolas, and a copy of this report, LIC811, and the appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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