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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004686
Report Date: 09/18/2024
Date Signed: 09/19/2024 06:58:06 AM

Document Has Been Signed on 09/19/2024 06:58 AM - 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/
DIRECTOR:		SONIA DEZHAMFACILITY TYPE:
735
ADDRESS:22761 SWEETMEADOWTELEPHONE:
(949) 233-1416
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 4DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:Sonia DezhamTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by staff. Nazanine Farshidian and Sonia Dezham, Administrators, arrived shortly after and met with LPA and LPA explained the nature of the visit. Facility is licensed for six ambulatory clients.
LPA Lyman along with Caregiver Fereioon Farzaneh toured the facility at 8:10 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of four client bedrooms, two shared hall bathrooms, client restroom, two staff rooms, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 105 and 106.1 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gate is unlocked, self latching and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. plan is thorough and complete. Facility provided documentation of last fire drill conducted on 08/10/2024 and drills are conducted quarterly. Facility provides activities in the form of outings in the community. At 9:00 AM, LPA reviewed four client files and three staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of training and all pertinent paperwork. CONTINUED ON LIC 809C DATED 09/18/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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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: SOUTH COUNTY CARE III
FACILITY NUMBER: 306004686
VISIT DATE: 09/18/2024
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All staff have proof of CPR training. At 9:30 AM, LPA reviewed medication storage and administration. Facility uses a medication administration record. Medications are stored in a locked cabinet and are being administered per physician order.



Based on the observations made during today’s visit, NO deficiencies are being cited. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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