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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 02/06/2023
Date Signed: 02/06/2023 11:17:48 AM

Document Has Been Signed on 02/06/2023 11:17 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: 5DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jom IsonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA Gutierrez met with Administrator (AD) Jom Ison and discussed the purpose of the inspection. During the inspection LPA Gutierrez and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a single-story house with five client bedrooms, and two bathrooms. During the inspection LPA observed three clients in care. Per AD, two additional clients were away on a community outing. Clients were observed in their bedroom and in the dining room area engaging in day program. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility has a 30-day supply of PPE on hand. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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