306005838-8-12-2020-22-AS-MBAT-BSF2XX-20200812174753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005838
Report Date: 08/12/2020
Date Signed: 08/12/2020 05:50:09 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:	GENTLE CARING HOME		FACILITY NUMBER:	306005838
ADMINISTRATOR:	LOURDES LAT, MARIA		FACILITY TYPE:	740
ADDRESS:	26762 CARLOTA DR.		TELEPHONE:	(949) 874-4426
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	08/12/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator (AD) Maria Lat		TIME COMPLETED:	03:00 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 1:00 PM Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with Administrator (AD), Maria Lat. The facility contains four (5) bedrooms with two (3) full bathrooms, is a single-story building with a 2-car garage. The inspection was as follows: Physical Plant: At 1:10 PM LPA Barrett conducted the virtual inspection and toured the inside and outside of this facility with the Administrator, 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 and the backyard gates were observed to be self-closing and self-latching. The kitchen was clean, and LPA observed the locked drawer where the knives and sharp utensils were to be stored as well as the locked cupboard where the centrally stored medications were to be kept. There were smoke two carbon monoxide detectors installed in the kitchen and in the living room that were observed to be operational. Smoke detectors were tested and observed throughout common areas as well as all of the bedrooms, were centrally wired and observed to be in good operation. There were five (5) exit doors of which only three (3) were equipped with alarms. The fire extinguishers was located in the kitchen and above the medication cabinet and were observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked cabinet that also contained the first aid kit. Bedrooms: There were five (5) bedrooms that were observed to have made beds, bedroom furniture, appropriate lighting. The rooms with 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: 08/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

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: GENTLE CARING HOME	FACILITY NUMBER: 306005838
	VISIT DATE: 08/12/2020

NARRATIVE

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Continued from page 1.

Bathrooms:
There were three (3) bathrooms which were equipped with grab bars in the showers and water temperatures from the faucets measured within 105 and 120 degrees F. LPA observed that the facility was missing non-skid mats for the showers.

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

Food Service:
There were no residents in the facility at the time of this inspection. LPA discussed the required food supply to be kept on hand per California Code of Regulations, Section 87555 (b)(26).

Records:
Staff and Resident files were planned to be kept at the facility and available for review.

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

Activities:
LPA discussed the facility's planned activities schedule which will be posted with activities staff and volunteers schedules for music, games, arts and crafts and exercises.

Due to items observed to be missing during this inspection, Technical Advisories were issued and a re-visit will be conducted on 8/14/2020 before this facility can be recommended for licensure.

An exit interview was conducted with the Administrator and a copy of this report, and LIC 9102 (Technical Advisory), was provided via email and an electronic read receipt confirms the delivery of this report.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

LIC809 (FAS) - (06/04)

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