<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005865
Report Date:
10/14/2020
Date Signed:
10/14/2020 10:03:07 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:
10/14/2020
TYPE OF VISIT:
Prelicensing
ANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Mark Mendez - Administrator
TIME COMPLETED:
10:00 AM
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 Analyst (LPA) Patricia Velazquez conducted an announced visit via phone FaceTime virtual technology to Respit Manor due to the Coronavirus Pandemic and precautionary measures. LPA Velazquez conducted the visit with Administrator Mark Mendez. The purpose of today's subsequent Pre-Licensing visit was to follow-up on the issues that were present during the initial Pre-Licensing visit dated 09/15/2020. The following issues were observed and required correction:
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
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2870
LICENSING EVALUATOR NAME:
Patricia Velazquez
TELEPHONE:
(714) 380-0440
LICENSING EVALUATOR SIGNATURE:
DATE:
10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
2
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:
10/14/2020
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
26
27
28
29
30
31
32
On today's phone FaceTime visit the aforementioned items have been addressed and corrected. The items reviewed during this visit are in compliance. The Pre-Licensing is complete and the facility appears ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.
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. Mr. 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:
10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/14/2020
LIC809
(FAS) - (06/04)
Page:
2
of
2