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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005393
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:06:37 PM


Document Has Been Signed on 03/01/2022 01:06 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:ORANGE COUNTY CARE HOME IFACILITY NUMBER:
306005393
ADMINISTRATOR:RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:23800 HILLHURST DRIVETELEPHONE:
(949) 322-1078
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Faith Rassouli TIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Faith Rassouli, her Administrator's certificate expires on 11/2/2023. LPA and Administrator toured the facility. LPA observed all resident bedrooms had the required furnishings. Smoke detectors/carbon monoxide detectors tested operational. Hot water in both bathrooms measured 111.2 degrees Fahrenheit to 112.2 degrees Fahrenheit. Both bathrooms were clean and operational. LPA and administrator toured the garage. The garage is used for storage and kept locked. LPA observed the garage side door is damaged at the bottom. The side exit gate is operational. There is a pool on the front of the house to the side of the front door. The pool is fenced and the gate is secured. The pool fencing meets regulation requirements. LPA and Administrator toured the backyard. The backyard has two seating areas for clients and visitors. The backyard area has two separate areas, the sitting areas that are accessible from the back door of the facility and the outer deck area that is only accessible through the pool side gate which is latched and operational. No obstacles or hazards observed in the backyard. LPA and Administrator toured the kitchen. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. LPA observed the knives are kept locked in a kitchen drawer. LPA observed the medications are kept locked in a cabinet in the laundry room. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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