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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 03/24/2022
Date Signed: 03/24/2022 09:31:58 AM

Document Has Been Signed on 03/24/2022 09:31 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: 3DATE:
03/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Administrator Jom Ison TIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct a case management for an incident. LPA met with Administrator (AD) Jom Ison; and stated the purpose of this visit.

On March 23, 2022, Community Care Licensing Division (CCLD) Orange Office received an incident report stating that on March 22, 2022 at 7:39 AM, Client was pronounced dead in the hospital. Client 1 was admitted in the hospital since March 13, 2022.

For this visit, LPA toured the interior of the facility and observed three clients in care; two staff members ; and two day program representatives on the floor. LPA toured the client's rooms and common areas. In the areas covered, LPA did not observed any immediate threat to the health and safety of the clients in care. LPA conducted interviews and did a file review. AD provided LPA with copy of the discharge summary from the hospital.

No citation was issued during this visit.

LPA Marin conducted an exit interview with AD Jom 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: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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