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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004686
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:02:42 PM

Document Has Been Signed on 09/15/2022 03:02 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:SOUTH COUNTY CARE IIIFACILITY NUMBER:
306004686
ADMINISTRATOR:SONIA DEZHAMFACILITY TYPE:
735
ADDRESS:22761 SWEETMEADOWTELEPHONE:
(949) 233-1416
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 4DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Sonia Dezham and Nazanine FarshidianTIME COMPLETED:
02:43 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Sherry Taghdimi and explained the reason for the visit. Administrators Nazanine Farshidian and Sonia Dezham arrived during the visit. Administrator Sonia Dezham has a current certificate expiring on 06/05/2023.

At 1:15 PM, LPAs toured the facility with Caregiver Sherry Taghdimi. Facility has 2 clients present during today's visit. All rooms are single occupancy. LPAs observed clients relaxing in the facility. LPAs spoke with clients present and all appeared happy and well taken care of. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the sign in sheet in the entrance of the facility. Facility takes client temperatures daily. The facility mitigation and infection control plan have been received. LPAs observed adequate emergency food as well as the first aid kit. First aid kit contained all required items. Smoke detectors tested operational during today's visit. LPAs observed locked medication closet. Fire extinguisher is charged. Facility has a thirty day supply of PPE on-site. LPAs toured the outside grounds and observed the outside shaded visitation area. Exit gate is unlocked and self latching. Clients enjoy community outings at least weekly. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. LPAs reviewed select client files during the visit and all were up to date including updated client emergency information.

LPA consulted with Administrator on the importance of mask wearing for visitors and staff inside the facility.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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