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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 02/03/2022
Date Signed: 02/03/2022 11:03:43 AM

Document Has Been Signed on 02/03/2022 11:03 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:MERYEMANAFACILITY NUMBER:
306005452
ADMINISTRATOR:ISON, JOMFACILITY TYPE:
734
ADDRESS:26491 ARACENA DRIVETELEPHONE:
(949) 426-1666
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 5CENSUS: 4DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Administrator Jom Ison TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA Marin met with Administrator (AD) Jom Ison; and stated the purpose of this visit.

This facility is a single level structure and licensed as an Adult Residential Facility for Persons with Special Health Needs (ARFPSHN) and with fire clearance of five non-ambulatory of which five may be bedridden. For this visit there were four clients in care.

About 10:00 AM, LPA Marin toured the interior and exterior portions of the facility with AD Ison. There were five private client's rooms. Rooms were provided with specialized bed and appropriate linens; adequate storage space and furniture in good repair. Built in lift tracking devices were tested and observed to be operational. Rooms with portable oxygen tanks were observed to be in a rack and kept away as a tripping hazard. Bathrooms were observed to be in good repair and with working built in lift device.. Hot water was measured at 105 degrees Fahrenheit. Centralized smoke and carbon monoxide detectors were tested to be operational. Fire extinguishers were mounted and charged. Facility sprinkler system was inspected last August 10, 2021. In the common areas, LPA observed clients doing activities. LPA observed several activity materials available for the client's use. Kitchen appeared clutter free. Facility met the minimum 2-day perishable and 7-day non-perishable food stock requirements. Sharp kitchen items and cleaning supplies were rendered inaccessible to clients in care. Medications were stored in a locked medication cart and cabinet. In the garage, the facility has a working emergency power back up source. Spare oxygen tanks were kept and secured in an appropriate holding rack. Facility has adequate supplies of protective personal equipment (PPE). Exterior portions have shaded areas and provided with good furniture in good repair. Facility has 2 special company vehicles for client's use. Vehicles were provided with first aid kit, fire extinguisher and suction machine. LPA reviewed the Coronavirus 2019 (COVID) 19 mitigation plan of the facility. LPA discussed with AD the latest public health order and the latest visitation requirements and procedures.

For this visit, no deficiency was observed. The facility is in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA conducted an exit interview with AD Ison; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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