306005781-9-29-2020-22-AS-MBAT-BTWUUC-20200929155319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005781
Report Date: 09/29/2020
Date Signed: 09/29/2020 03:53:58 PM

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:	OHANA CARE		FACILITY NUMBER:	306005781
ADMINISTRATOR:	FISK, RYAN & FISK,BRIGITTE		FACILITY TYPE:	740
ADDRESS:	25875 VIA VIENTO		TELEPHONE:	(949) 916-1830
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/29/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator (AD) Ryan Fisk		TIME COMPLETED:	12:00 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	At 10:00 AM Licensing Program Analysts (LPAs), Mike Barrett and Criss Trinidad, contacted the facility via FaceTime App to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPAs identified themselves and discussed the purpose of the announced video call with Administrators (ADs) Ryan Fisk and Bridgette Fisk. The facility contains 7 bedrooms with 5 bathrooms , is a single-story building with a 2-car garage. This pre-licensing inspection was due to a change in ownership and the facility had six (6) residents in care at the time. The inspection was as follows: Physical Plant: At 10:10 AM LPA conducted the virtual inspection and toured the inside and outside of this facility with ADs, including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways. The kitchen was clean, and knives were stored in a locked drawer. There are smoke/carbon monoxide detectors installed throughout common areas as well as all of the bedrooms which are centrally wired and observed to be in good operation. LPA observed that there were alarms installed on all of the exit doors that were observed to be functional. Fire extinguisher was observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked cabinet in kitchen area and a complete first aid kit was located in the hallway under the by the linen closet. The washer and dryer and cleaning supplies were located in the garage which was locked with a keypad entry door handle. Bedrooms: Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020

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: OHANA CARE	FACILITY NUMBER: 306005781
	VISIT DATE: 09/29/2020

NARRATIVE

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Continued from page 1.

Bathrooms:
Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures from the faucets were regulated by an electronic gauge set to 115 degrees F.

Supplies:
There was a sufficient supply of toilet paper and hand soap as well as a sufficient stock of linens.

Food Service:
The facility met the 2-day perishable and 7-day nonperishable on hand food supply as LPA observed fresh fruit, canned goods, bread, dairy products, eggs, frozen meats and cereals in both the kitchen and garage. The food was observed to be stored appropriately and away from cleaning supplies.

Records:
Resident files were kept at the facility and available for review and staff files were kept at the facility's main office and available for review upon request.

Administration:
LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-Us-No” poster posted in the facility.

Component III Orientation points were discussed and was waived due to Licensee manages multiple facilities and is familiar with components of orientation.

The Pre-Licensing inspection is now complete and this facility is recommended for licensure and Centralized Application Bureau will be notified.

An exit interview was conducted with Administrator Ryan Fisk via telephone and a copy of this report was provided to Administrator Fisk via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020

LIC809 (FAS) - (06/04)

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