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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005781
Report Date: 10/15/2021
Date Signed: 10/15/2021 11:31:43 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:OHANA CAREFACILITY NUMBER:
306005781
ADMINISTRATOR:FISK, RYAN & FISK,BRIGITTEFACILITY TYPE:
740
ADDRESS:25875 VIA VIENTOTELEPHONE:
(949) 916-1830
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Brigitte FiskTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted by staff. LPA was screened for symptoms of Covid-19. LPA was granted entry by staff. LPA explained the reason for the visit. Administrator Brigitte Fisk arrived at 10:57 am. LPA and Administrator toured the facility. Facility has 7 bedrooms, one for room is for staff and 5 bathrooms. All resident bedrooms had the required furniture and were clean and organized. All 5 bathrooms were clean and operational. LPA observed the fireplace in the living was screened. Smoke detectors/carbon monoxide detectors tested operational. LPA toured the kitchen. The kitchen was clean and organized. LPA observed a 2-day perishable and 7-day non-perishable food supply on hand. LPA did not observe any obstacles or hazards in the facility. LPA and Administrator toured backyard of the facility. The patio has a seating area for the residents. The exit gate is operational. No bodies of water observed. LPA did not observe any hazards in the backyard. LPA inspected the garage. The garage is kept locked and used for storage. Facility has submitted a mitigation plan that is pending approval. Based on today's visit no deficiencies are being cited. An exit interview was conducted with the Administrator and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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