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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005762
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:14:31 AM


Document Has Been Signed on 04/25/2022 11:14 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:RELIANCE SENIOR HOMEFACILITY NUMBER:
306005762
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24672 ELOISA DRTELEPHONE:
(949) 295-6854
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ray SantianezTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual inspection (mitigation) in this facility. LPA was greeted and granted entry by MaryJane Aroso, Caregiver. Ray Santianez, Administrator joined shortly at 9:55 AM and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory residents of which one may be bedridden and has a hospice waiver for six residents. There are no residents in hospice care. LPA was granted entry after completing the Coronavirus 2019 (COVID-19) screening procedure. For this visit, there are five residents in care and two staff members on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 130.6 degrees Fahrenheit in Bathroom #1, 134.6 degrees Fahrenheit in Bathroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. The fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture under an umbrella cover. The grounds were free of tripping hazards. Side exit doors were self-latching and self-closing. LPAs reviewed the approved COVID-19 Mitigation Plan.

For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and LPA Cho will follow-up with the corrections. An exit interview was conducted with Ray Santianez, Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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