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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005865
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:09:09 PM


Document Has Been Signed on 02/22/2024 12:09 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 MANORFACILITY NUMBER:
306005865
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23255 RESPIT AVETELEPHONE:
(949) 460-0317
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Facility Administrator - Mark MendezTIME COMPLETED:
12:26 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted by facility administrator (AD) Mark Mendez about the visit.

For today’s visit, LPA met with AD Mendez and observed a total of 6 residents in care.

LPA observed the Administrator's Certificate for facility administrator (AD) Mark Mendez which expires on 9/26/2024.

LPA De Perio toured the interior and exterior portions of the facility with AD Mendez. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 2 may be on hospice and 1 bedridden. For this visit, there are a total of 6 residents in care. LPA De Perio observed the PUB475 "See Something Say Something" poster posted in the kitchen. There are a total of 6 bedrooms, of which are 4 private resident rooms and 1 is a shared resident room. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 106.9 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: RESPIT MANOR
FACILITY NUMBER: 306005865
VISIT DATE: 02/22/2024
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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the facility hallway. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. LPA De Perio observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

No citations were issued.

An exit interview was conducted with AD Mendez.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2