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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005782
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:04:10 PM


Document Has Been Signed on 06/12/2024 01:04 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:RESPIT MANOR MISSION VIEJOFACILITY NUMBER:
306005782
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23412 VIA GUADIXTELEPHONE:
(949) 331-7578
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 3DATE:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mark Mendez- AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings in connection to Complaint Control Number: 22-AS-20240606140114. LPA stated the purpose of the visit to Administrator Mark Mendez. LPA observed Staff #1 (S1) was not associated per the Licensing Information System (LIS) and the Guardian Employee Roster dated June 12, 2024 as required per the Criminal Record Clearance of the Title 22 Regulations. S1 stated that they were employed approximately June or July 2022.

A deficiency is being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted with Administrator Mark Mendez, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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Document Has Been Signed on 06/12/2024 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...

This requirement was not met as evidenced by:
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Administrator stated they will request in writing to associate S1 and to provide proof of access to Guardian, and to submit an Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.
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Based on observation, interviews, and record review, S1 was not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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