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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004273
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:42:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/07/2022 02:42 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:NANA'S GARDENFACILITY NUMBER:
306004273
ADMINISTRATOR:BRIGITTE/DONALD FISKFACILITY TYPE:
740
ADDRESS:26531 NACCOMETELEPHONE:
(949) 770-2722
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Brigitte Fisk, AdministratorTIME COMPLETED:
03:00 PM
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On 10/07/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection mostly focused on Infection Control procedures. LPA was greeted and granted entry by Administrator Brigitte Fisk after undergoing the COVID-19 screening procedure and explaining the purpose of the visit.

At approximately 2:35pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently six (6) residents in care, four (4) of which are receiving hospice care. Residents are observed relaxing in their respective bedrooms or in the facility's common areas. All appear clean and well taken care of. The bedrooms include all necessary components of furnishing. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. An ample supply of linen is observed.

Sharp instruments are kept in a locking box on the kitchen counter. Cleaning supplies are located in the attached garage which is equipped with a code keyless entry. The centrally stored medication is located in a locked cabinet in the dining room. LPA observed a sufficient supply of food and water present.
LPA observed the facility has COVID-19 Precautions posters and all required department postings along with hand washing signs. The fire extinguisher present is charged and has up-to-date maintenance shown on the attached tag. Staff present is adequately cleared and associated in Guardian.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NANA'S GARDEN
FACILITY NUMBER: 306004273
VISIT DATE: 10/07/2022
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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and multiple shaded areas are present in the backyard for the enjoyment of residents and visitors. The exit gates on both sides of the house are self-latching and easy to open in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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