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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005765
Report Date: 02/27/2024
Date Signed: 02/27/2024 05:09:21 PM

Document Has Been Signed on 02/27/2024 05:09 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
ORANGE COUNTY RO, 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: 6DATE:
02/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Ryan Cruz, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management inspection documenting a deficiency observed during the investigation of complaint #22-AS-20240214122109.

Due to the presence of structural damage to the outside patio, the backyard of the facility is currently found to be inaccessible to residents in care. A type B deficiency is cited on the attached form LIC809-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/27/2024 05:09 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 02/27/2024 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NORA'S PLACE 1
FACILITY NUMBER: 306005765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited

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Per CCR 87219(h)(2) on Planned Activities: "Facilities shall provide sufficient space to accommodate (...) outdoor activities. Activities shall be encouraged by provision of: Outdoor activity areas which are easily accessible to residents and protected from traffic. This requirement is not met as
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evidenced by: Based on observation and interviews, the backyard is currently inaccessible to residents in care due to damage sustained to the patio shade structure. This constitutes a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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