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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004687
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:54:13 AM


Document Has Been Signed on 08/19/2022 10:54 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:ADRIANA'S SENIOR CARE LIVINGFACILITY NUMBER:
306004687
ADMINISTRATOR:RICHARD MENDOZA, JR.FACILITY TYPE:
740
ADDRESS:25392 ADRIANA STREETTELEPHONE:
(949) 273-5625
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Manager Kevin MendozaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Manager Kevin Mendoza (HM) and stated the purpose of this visit.

About 9:39 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA toured the interior and exterior portions of the facility. This facility is a single level structure and licensed for 6 bedridden and with hospice waiver for six. On this visit, there was one resident under hospice care. LPA observed six residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility with HM . There were six private resident's rooms, which were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were observed to be operational. Bathrooms were provided with handrails; and water fixtures were observed to be in good repair. Hot water was measured at 122 degrees Fahrenheit. Medications, and cleaning supplies were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self closing. LPA reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA also discussed the California Code of Regulations (CCR) Section 87470 Infection Control Requirements. Administrator's certificate of Administrator Adriana Mendoza is valid until 04/06/2023. HM was informed to send all incident reports and general correspondence to CCLASCPOrangeCountyRO@dss.ca.gov

No citation was issued for this visit.

LPA Marin conducted an exit interview with HM Mendoza and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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