306005310-5-2-2022-22-AS-JCHO-CE2UY4-20220502155920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005310
Report Date: 05/02/2022
Date Signed: 05/02/2022 03:59:27 PM

Document Has Been Signed on 05/02/2022 03:59 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:	QUEEN'S HOME 2		FACILITY NUMBER:	306005310
ADMINISTRATOR:	MAGHBOULEH, KATAYOUN		FACILITY TYPE:	740
ADDRESS:	26545 AVENIDA DESEO		TELEPHONE:	(949) 716-1907
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	05/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Arlene Mahinay		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual (mitigation) inspection to this facility. LPA was greeted and granted entry by House Manager (HM) and Administrator (AD) Arlene Mahinay and completed the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of this visit and inspected the facility with the AD. The facility is a single level structure and licensed for six non-ambulatory residents of which all may be bedridden and has a hospice waiver for four residents. There are 3 residents in hospice care as of today. For this visit, there are six residents in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms tested operational except for the auditory alarm in Bedroom #3. Bathrooms were observed to be in good repair and provided with handrails. A non-skid floor mat was provided in Bathroom #6 since all residents shared the shower. Hot water was measured between the ranges of 69.6 degrees Fahrenheit in Bathroom #3 and 119.1 degrees Fahrenheit. LPA did not inspect Bedroom #3 and Bedroom and Bathroom #5 per the resident's request. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. The fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture under a canopy. The grounds were free of tripping hazards. Side exit doors were self-latching and self-closing. LPA reviewed the approved COVID-19 Mitigation Plan.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

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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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: QUEEN'S HOME 2	FACILITY NUMBER: 306005310
	VISIT DATE: 05/02/2022

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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.

For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and AD will follow-up with the corrections. An exit interview was conducted with Administrator Arlene Mahinay and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

LIC809 (FAS) - (06/04)

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