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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005765
Report Date: 05/27/2021
Date Signed: 05/27/2021 09:49:55 AM

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:NORA'S PLACE 1FACILITY NUMBER:
306005765
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:25612 ADRIANA STREETTELEPHONE:
(949) 273-9951
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Mark Cruz, AdministratorTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Melanie Moreno and explained the reason for the visit. Administrator Mark Cruz arrived shortly after.

At 8:35 AM, LPA August toured the facility with Melanie Moreno. There are five residents residing in the facility and no active covid-19 cases. LPA observed all five residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking client's temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply. LPA observed the PPE supply of surgical masks, gowns and gloves in the garage. LPA consulted with Administrator Cruz regarding community cloth towels in restrooms and ensuring the paper towels are always stocked. Facility has LIC808 Mitigation Plan awaiting approval.

No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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