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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004521
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:34:03 PM


Document Has Been Signed on 03/18/2022 02:34 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:JUST LIKE HOME IVFACILITY NUMBER:
306004521
ADMINISTRATOR:ROBERT MASSUCOFACILITY TYPE:
740
ADDRESS:508 S. LAURINDATELEPHONE:
(714) 290-5440
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Marcela Elbo, Caregiver
Roda Paderna, Administrator		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Marcela Elbo, caregiver after explaining the purpose of the visit and being temperature checked. Administrator Roda Paderna was called and arrived later to assist with visit.

At approximately 1:45pm, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently five (5) residents in care, two (2) of which are currently on hospice. Residents are observed to be relaxing in their bedroom or in the common areas are appear well taken care of. The bedrooms include all necessary components and sufficient quantity of linen is observed also. Facility appears to be clean, sanitary and free of odors in all areas inspected. Cleaning supplies, sharp instruments and toxic substances are stored in locked cabinets and drawers.

LPA observed the facility has COVID-19 Precautions posters and required department postings as well as hand washing signs. Facility has an adequate supply of PPE and emergency supplies. A LIC808 Mitigation has been submitted on 05/26/2021.
LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked in a kitchen cabinet. LPA toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard. The gate on one side of the house is equipped with a padlock while the other side is easy to open and self-latching.

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. A Technical Advisory is issued in regards to the locked backyard gate. This report was reviewed with facility representative and a copy of this report 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: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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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