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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005782
Report Date: 04/26/2022
Date Signed: 04/26/2022 12:41:56 PM


Document Has Been Signed on 04/26/2022 12:41 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
CCLD Regional Office, 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: 4DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Mark Mendez TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. Administrator (AD) Mark Mendez arrived in the facility shortly after. LPA stated the purpose of this visit.
LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were four residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were three private and one shared resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and non-skid floor mats. Hot water was measured at 105 degrees Fahrenheit. Medications, cleaning supplies and sharp items were inaccessible to residents in care. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self closing and self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Administrator's certificate is valid until September 26, 2022. LPA discussed guidelines in use of video surveillance system in the facility.

For this visit, no deficiency was observed for areas covered. No citation was issued.

LPA Marin conducted an exit interview with AD Mendez. Copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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