306005865-9-15-2020-22-AS-PVEZ-BTGQ9W-20200915115900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005865
Report Date: 09/15/2020
Date Signed: 09/15/2020 11:59:08 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:	RESPIT MANOR		FACILITY NUMBER:	306005865
ADMINISTRATOR:	MENDEZ, MARK		FACILITY TYPE:	740
ADDRESS:	23255 RESPIT AVE		TELEPHONE:	(949) 460-0317
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	09/15/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mark Mendez - Administrator		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	Licensing Program Analysts (LPAs) Patricia Velazquez and Criss Trinidad conducted an announced Pre-Licensing visit with Component III Orientation via phone FaceTime virtual technology to Respit Manor due to the Coronavirus Pandemic and precautionary measures. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 01/03/2020 for a capacity of 6 residents. LPAs Velazquez and Trinidad along with Administrator Mendez observed the following: Structure: Facility is a one story house with 5 resident bedrooms, 2.5 bathrooms, living room, dining area, and kitchen. The dining area has 3 small tables with seating for 2 residents at each table. The facility has a beige stucco exterior with white trim. There is an attached 2 car garage that houses the washer and dryer. There is a front yard that has grass, bushes, and plants. There is a small concrete patio area with seating in an area leading to the front door. The backyard has a shaded concrete area with seating for residents as well as a large grassy area with trees and plants. Signal System: The facility's central heating and air conditioning is controlled by a thermostat located in a hallway. Each resident is equipped with a call button to summon staff when they need assistance. Bedrooms Residents: All bedrooms accommodate residents with one bedroom accommodating a bedridden resident. The resident bedrooms accommodate residents' furnishings with all required furniture present. Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower. Grab bars were present as a well as a non-skid mat.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020

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: RESPIT MANOR	FACILITY NUMBER: 306005865
	VISIT DATE: 09/15/2020

NARRATIVE

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Linens and Hygiene Supplies:
Adequate supply of linens is stored in two hallway closets along with extra hygiene supplies stored in the storage room.
Emergency Phone Numbers, Exit Plan:
Readily available for review in the living room.
Food Service and Menu:
There was an adequate supply of 7 day non-perishable and 2 day perishables present in the facility. The sample menu was posted on the refrigerator. Additional food supplies are stored in a cabinet located in the garage.
Smoke and Carbon Monoxide Detectors:
Smoke alert systems are hardwired were tested and found operational. The carbon monoxide detector located in the hallway was tested and found operational.
Fire Extinguisher:
Fully charged and mounted on a wall in the kitchen.
Fire Clearance:
Approved on 08/25/2020 for 3 ambulatory residents, 2 non-ambulatory residents, and 1 bedridden resident.
Appliances:
Gas four burner stove, single oven, dishwasher, microwave, and a refrigerator/freezer The washer and dryer are located in the garage and noted to be operational.
Toxins:
Some were locked and stored in a locked cabinet located in the garage.
Water Temperature:
Tested and recorded at 105.6 degrees Fahrenheit in bathroom 1, at 106.0 degrees Fahrenheit in bathroom 2, and 108.2 degrees Fahrenheit in bathroom 3.
Medications, First Aid Kit & Manual:
First Aid kit is stored in a locked hallway closet. Medication was stored in a separate locked medication cart located in the locked hallway closet.
Resident and Staff Files:
Resident records were kept in a locked closet located in a hallway. Staff records were kept in a separate file cabinet located in the garage.
Reading Material, Games, Equipment, & Materials:
The facility has activities that commensurate with their plan of operation.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020

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: RESPIT MANOR	FACILITY NUMBER: 306005865
	VISIT DATE: 09/15/2020

NARRATIVE

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Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

The following items need to be addressed prior to licensure:

Obtain the appropriate Fire Clearance
Ensure entry gate is self-closing and self-latching
Obtain a First Aid manual
Obtain Complaint Poster in 20 by 26 inch size
Obtain mattress pads for resident beds
Remove cleaning supplies that are stored next to food supplies in the storage room
Separate resident medication into individual resident locked boxes
Properly lock cleaning supplies and over the counter medications/vitamins
Obtain emergency lighting
Replace inoperable night lights
Obtain emergency food supplies
Obtain trash cans with lids
Remove black grease stains surrounding each stove top burner
Remove black grease stains from pots and pans or obtain a new set
Remove the extra table and old recliner from the back yard
Remove gray stains in toilet bowl in bathroom

The facility is not ready for licensure and LPA Velazquez will conduct another Pre-Licensing visit to review the items listed above. An exit phone interview was conducted with Administrator Mark Mendez and a copy of this report was signed by LPA Patricia Velazquez. This report will be sent via email to Mr. Mark Mendez who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Mendez agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange. LPA Velazquez provided the RO address to Administrator Mark Mendez.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020

LIC809 (FAS) - (06/04)

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