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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004680
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:38:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/28/2022 03:38 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:F & G CARE HOMEFACILITY NUMBER:
306004680
ADMINISTRATOR:AUGUSTUS A. TORRESFACILITY TYPE:
735
ADDRESS:24672 RHEA DRIVETELEPHONE:
(949) 273-5022
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gilbert Roque, caregiverTIME COMPLETED:
10:30 AM
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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 caregiver Gilbert Roque after explaining the purpose of the visit and being screened for COVID-19. Administrator Augustus Torres was notified of the visit by staff.

At approximately 9:20am, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently four (4) clients in care. At the time of the visit, all four clients are attending their day program in person and are away from the facility. The bedrooms include all necessary components. The bathroom is equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected. Staff present is observed to be correctly associated in Guardian. Sharp instruments are kept in a cabinet secured by a key lock as well as cleaning supplies and toxic substances. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted.

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. The exterior of the facility is free of debris and obstruction, with a shaded area where outdoor furniture is located for the clients' and visitors' enjoyment. The perimeter gates are self-latching and can easily be opened in an evacuation.

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 was provided and left at facility.

As FAS encountered technical issues during the visit, LPA came back later on the same day to review and deliver report to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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