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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005663
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:08:39 PM

Document Has Been Signed on 09/15/2022 02:08 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:ALLIANCE SENIOR CAREFACILITY NUMBER:
306005663
ADMINISTRATOR:GACAD, EVELYNFACILITY TYPE:
740
ADDRESS:24362 APHENA AVETELEPHONE:
(714) 588-9228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: DATE:
09/15/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Antonio GacadTIME COMPLETED:
02:24 PM
NARRATIVE
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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. LPA explained the reason for the visit. LPA and staff toured the facility. During the visit Administrator Antonio Gacad arrived, his Administrator's certificate expires 5/29/2023. Facility has 7 bedrooms (1 is for staff), 2 bathrooms, living room, dining room, kitchen and a 2 car garage. Inside the garage is a small storage room. LPA observed oxygen tanks and furniture in the storage room. The garage is kept locked and used for storage. LPA observed medication is kept locked in a hall closet. LPA observed the PUB 475 sign (See Something, Say Something sign) measured 8 1/2 by 11 inches and was posted next to the kitchen and not by the entrance of the facility. Hot water measured 105.2 degrees Fahrenheit in both bathrooms. LPA observed both bathrooms were clean and operational. LPA observed that cleaning supplies were kept locked under the bathroom sinks. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen is fully charged. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA observed the kitchen is clean and organized. The stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed cleaning and laundry supplies are kept locked in a cabinet next to the washing machine. LPA toured the backyard. There is a shaded seating area for residents to sit outside. Both exit gates are operational. No bodies of water observed. No obstacles or hazards observed. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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