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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005393
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:13:39 PM


Document Has Been Signed on 03/11/2024 03:13 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
ORANGE COUNTY RO, 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:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fahimeh Rasouli- AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPA was greeted and granted entry by Caregiver Lino Dulatre and stated the purpose of the visit. LPA observed six residents and two caregivers on duty. Administrator (Admin) Fahimeh Rasouli arrived on premise at 9:58am.

The facility is a single story home comprised of the following: six resident bedrooms, two caregiver bedrooms, two resident bathrooms, laundry room, living/dining room, kitchen, backyard patio, front swimming pool area, and an attached two-car garage. LPA toured the outside grounds. There was shading and sufficient seating for the residents. The exit gate was self-closing and self-latching. The swimming pool was gated and secured. LPA observed the resident bedrooms which had all required elements with ample lighting. LPA observed one out of the two resident bathrooms had a strong urine odor which was cleaned during the visit. Showers were sanitary, faucets, toilets, and grab bars were operational. The hot water temperature measured at 119.8 and 111.5 degrees Fahrenheit in the resident bathrooms. There were sufficient, clean supply of linens. LPA observed the two-day supply of perishables and the seven-day supply of non-perishables including the emergency food and water. LPA observed 20 expired canned items/sauces in the pantry that were disposed during the visit. LPA observed oil residue in the pantry shelves which will require a deep cleaning. LPA reviewed the receipts of the weekly treatments serviced by the pest control company to eradicate cockroaches after observing one live and three dead cockroaches while auditing the pantry items. The last three services per receipts were on March 1, 2024, February 21, 2024, and February 16, 2024. A cockroach trap was observed on the floor of the pantry. The carbon monoxide, smoke detectors, and the auditory devices were tested and operational. The first extinguisher located in the kitchen was purchased on February 26, 2024. Medications, sharps, and toxins were locked and inaccessible to the residents. LPA observed the Complaint Poster (PUB 475) in the required size of 20"x 26." LPA reviewed six out of the six resident files/medications and the two staff files during today's visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ORANGE COUNTY CARE HOME I
FACILITY NUMBER: 306005393
VISIT DATE: 03/11/2024
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Administrator was advised on the following items: to ensure that the bathroom and kitchen pantry are kept clean, sanitary, and odorless at all times, kitchen area to be free of insects, and food served to be of good quality that is not expired.

Based on today's observations, no deficiency is being cited as per the Title 22 Division 6 Chapter 8 of the California Code of Regulations. (2) Technical Advisories and (1) Technical Violation will be issued.

An exit interview was conducted with Administrator Fahimeh Rasouli, and a copy of this report was provided via email at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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