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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005585
Report Date:
09/03/2021
Date Signed:
09/03/2021 01:43:26 PM
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:
VIVIDUS SENIOR LIVING
FACILITY NUMBER:
306005585
ADMINISTRATOR:
SHARIFAN, BAABAK
FACILITY TYPE:
740
ADDRESS:
25131 VIA PORTOLA
TELEPHONE:
(949) 584-0920
CITY:
LAGUNA NIGUEL
STATE:
CA
ZIP CODE:
92677
CAPACITY:
6
CENSUS:
5
DATE:
09/03/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:55 PM
MET WITH:
Marco Tambaoan
TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff Marco Tambaoan. LPA and staff toured the facility. Facility has 5 bedrooms and 3 bathrooms. Smoke detectors were tested and are operational. The garage contains extra supplies of cleaning products and food. The kitchen is clean and organized. LPA observed medications are kept locked in the kitchen pantry. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. LPA did not observe any obstacles or hazards in the facility. LPA toured the backyard of the facility. No bodies of water observed. Backyard has a sitting area with tables and chairs for residents to sit outside. Both backyard exits are latched and secured. LPA did not observe any obstacles or hazards in the backyard. Facility mitigation plan (LIC 808) is pending approval. No deficiencies are being cited. LPA conducted an exit interview with staff and a copy of the report was provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/03/2021
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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