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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005452
Report Date: 02/26/2025
Date Signed: 02/26/2025 04:07:41 PM

Document Has Been Signed on 02/26/2025 04:07 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:MERYEMANAFACILITY NUMBER:
306005452
ADMINISTRATOR/
DIRECTOR:		ISON, JOMFACILITY TYPE:
734
ADDRESS:26491 ARACENA DRIVETELEPHONE:
(949) 426-1666
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 5CENSUS: 5DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Jom Ison, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On February 26, 2025, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by DSP/LPT staff Kana Maeda. Administrator Jom Ison was notified of the visit via telephone and arrived later to assist. LPA met with the administrator and explained the purpose of the inspection.

During the inspection, LPA accompanied by facility staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with five private bedrooms, two bathrooms, and attached two car garage which is used for storage. All resident bedrooms have the required furnishings. LPA observed all client beds had linens and blankets. The backyard has a shaded sitting area along with a shed that is verified to be used for storage of cleaning supplies and paper products. LPA observed one client returning from a community outing. Two clients are observed participating in activities in the facility's common areas with day program staff. Other clients are resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 109 and 113F degrees at two faucets used for personal grooming.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers in addition to an emergency folder including information for all five clients in the event of an evacuation. Fire and evacuation drills verified also. Smoke detectors and carbon monoxide detectors tested operational. There are two fire extinguishers on the premises. Both were observed to be fully charged with up-to-date maintenance tags. There are go-bags with necessary supplies for evacuation and maintenance of aspiration equipment, oxygen delivery systems and gastrostomies. The facility is equipped with back-up batteries that are routinely verified to prevent power outages.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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: MERYEMANA
FACILITY NUMBER: 306005452
VISIT DATE: 02/26/2025
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CONTINUED FROM FORM LIC809
LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cart was observed to be locked. LPA reviewed five client records and five staff files which were found to include all necessary components. Staff members verified to have been completed the appropriate level of the Direct Service Provider training based on their seniority at the facility. All staff present are cleared and associated to the facility in Guardian.

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 provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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