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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005184
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:48:56 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2022 10:48 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:PREMIUM FAMILY CAREFACILITY NUMBER:
306005184
ADMINISTRATOR:IONESCU, EMANUELFACILITY TYPE:
740
ADDRESS:26732 AVENIDA SHONTOTELEPHONE:
(949) 452-0535
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Naomi IonescuTIME COMPLETED:
10:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at Premium Family Care to conduct an unannounced required annual inspection. LPA Cho was greeted and granted entry by Kayla Ionescu and Lidia Kui and spoke to Administrator Emanuel Ionescu via a telephone call. LPA stated the purpose of this visit. During the phone conversation, Admin indicated that there are no residents since the facility was licensed and wants to keep the license active. At 10:35am, LPA met with Naomi Ionescu.

The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden and has a hospice waiver for three. LPA toured the interior and exterior portions of the facility. There were two shared and two private resident rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA confirmed during the visit that there was no resident in care.

LPA provided to the following guidance to Administrator Emanuel and Naomi Ionescu: to report to Community Care Licensing Division prior to accepting a resident to conduct a follow-up health and safety inspection.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations. LPA Cho conducted an exit interview with Naomi Ionescu, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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