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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004680
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:20:58 PM

Document Has Been Signed on 08/04/2023 04:20 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
ORANGE COUNTY RO, 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:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Gilbert Roque, caregiverTIME COMPLETED:
04:40 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on an Serious Incident Report submitted to the Department by facility staff on June 9, 2023. LPA was greeted and granted entry by Gilbert Roque, caregiver after introducing himself and stating the purpose of the visit.

On June 8, 2023, client C1 briefly left the facility through his bedroom window and was unattended from approximately 11pm until 1am the next day when he was found and brought back to the facility. LPA interviewed staff and confirmed that C1 is attending an adult day program on his own as well as working at a fast food restaurant multiple days a week. A review of C1's physician report dated September 6, 2022 confirms that C1 is able to leave the facility unassisted.

No deficiencies cited today per Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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