306005647-10-19-2022-22-AS-JCHO-CKCR9W-20221019125012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005647
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:51:12 PM

Document Has Been Signed on 10/19/2022 12:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFIC SUN SENIOR CARE		FACILITY NUMBER:	306005647
ADMINISTRATOR:	DADABHOY, MUQEET		FACILITY TYPE:	740
ADDRESS:	24532 SPARTAN STREET		TELEPHONE:	(949) 600-5346
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Maria Susan Orlanes		TIME COMPLETED:	01:08 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/19/2022 at 10:04am, Licensing Program Analyst (LPA) Jessica Cho arrived at Pacific Sun Senior Care to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year with an emphasis on Infection Control. At 10:08am, LPA Cho met Caregiver Alicia Santos in front of the facility and entered the facility together. LPA completed the Coronavirus 2019 (COVID-19) screening procedure and met with Caregiver Maria Susan Orlanes. At 10:14am, LPA contacted Administrator (Admin) Muqeet Dadabhoy and stated the purpose of the visit. LPA discussed the past due annual licensing fee. Admin paid the fee during the visit and provided proof of payment via text at 12:47pm. In addition, Admin designated Caregiver Orlanes to assist with the tour, attend the exit interview, and sign the report on behalf of Admin. There are no active COVID-19 cases as of today. Facility does not document daily temperatures of visitors, residents, and staff on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) met the size requirement. The Administrator's Certificate for Muqueet Dadabhoy expires on 03/27/2023 and 09/16/2023 for Edilberto T Bernadino. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently four residents living in the facility of which two are receiving hospice care. At 10:33am, LPA Cho conducted a tour of the physical plant with Caregiver Maria Susan Orlanes. The single story home consists of six resident bedrooms and four resident bathrooms. There is one private staff bedroom and bathroom in the facility. The facility also has a living room, family room, kitchen, and garage with laundry. LPA inspected the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperatures and the water temperatures measured at 105.8 degree Fahrenheit in Bathroom #1, 105.6 degree Fahrenheit in Bathroom #2, 107.4 degree Fahrenheit in Bathroom #3, and 106.7 degree Fahrenheit in Bathroom #4.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC SUN SENIOR CARE	FACILITY NUMBER: 306005647
	VISIT DATE: 10/19/2022

NARRATIVE

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LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was not mounted, fully charged, and serviced on 06/31/2022. Smoke/carbon monoxide detectors were tested and operational. Auditory devices were not present on all emergency exits/doors and were removed during the facility renovation. Admin was instructed to install auditory devices on all emergency exits/doors. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA observed the following areas needed repair: a wooden block was used as a barricade to prevent entry into the garage from the living room due to the keypad lock not operating and the freezer door did not close properly causing water to leak. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. LPA observed sufficient supply of emergency food/water and PPEs.

At 12:35pm, LPA consulted the following with Administrator Muqeet Dadabhoy via a telephone call: to install auditory devices on all emergency exits/doors, to install a locking mechanism to the caregiver's room, to repair the garage keypad lock and freezer door, and to mount the fire extinguisher.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Caregiver Maria Susan Orlanes, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

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