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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 12/14/2021
Date Signed: 12/15/2021 04:18:24 PM

Document Has Been Signed on 12/15/2021 04:18 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:MERYEMANAFACILITY NUMBER:
306005452
ADMINISTRATOR:ISON, JOMFACILITY TYPE:
734
ADDRESS:26491 ARACENA DRIVETELEPHONE:
(949) 426-1666
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 5CENSUS: DATE:
12/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Jom IsonTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct a case management. LPA met with Administrator (AD) Jom Ison; and stated the purpose of this visit.

On December 12, 2021, AD Ison sent a report to Community Care Licensing Division (CCLD) Orange Office. The report stated that at 8:36 PM of December 11, 2021, emergency medical personnel arrived in the facility to assess Client 1. Paramedics pronounced Client 1 dead at 8:38 PM. The Orange County Sheriff's Deputy was also in the facility to follow up the case. Later that night, mortuary services was notified; and removed the body out of the facility.

For this visit, LPA conducted a tour of the facility. LPA observed four clients in care and five staff members on the floor. LPA toured the client's rooms and common areas. LPA did not observed immediate threat to the health and safety of the clients in care. LPA conducted interviews and did a file review. AD provided the LPA with working copy of the Death Certificate provided by the mortuary. The report stated that the immediate cause of death is cardiopulmonary arrest. AD agreed to follow up the official death certificate; and will provide Community Care Licensing Division once the document becomes available.

No citation was issued during this visit.

LPA Marin conducted an exit interview with AD Ison and copy of this report was left in the facility.


*** This is an amended report ***
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
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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