306005866-9-19-2022-22-AS-KSGH-CJEV4C-20220919160607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005866
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:06:20 PM

Document Has Been Signed on 09/19/2022 04:06 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:	ELEONOR'S PLACE 2		FACILITY NUMBER:	306005866
ADMINISTRATOR:	AVENDANO, DARYLL		FACILITY TYPE:	740
ADDRESS:	24772 ARGUS DRIVE		TELEPHONE:	(949) 547-5377
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Mark Cruz, administrator		TIME COMPLETED:	04:20 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	On 09/19/2022 at 3:00pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregiver Amelia Blando and explained the purpose of the visit after being temperature checked. Administrator Mark Cruz was notified by phone and arrived shortly afterwards to assist with the visit. At approximately 3:20pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently six (6) residents in care, three (3) of which are receiving hospice care. Residents are observed relaxing in the facility's common areas or in their respective bedrooms. All appear clean and well taken care of. The four individual and one shared bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are kept in a locked cabinet in the kitchen along with cleaning supplies. More cleaning supplies are secured in the attached garage where the laundry room is located. The centrally stored medication is located in a locked closet next to the entrance door. LPA observed a sufficient supply of food and water present. Emergency water is also stored in the attached garage. The facility has an ample supply of linen available for use by clients. LPA observed the facility has COVID-19 Precautions posters and all required department postings along with hand washing signs. Staff present is adequately cleared in Guardian. However one caregiver is shown not to be associated at the time of the visit. The fire extinguishers present are charged and have up-to-date maintenance shown on the attached tag. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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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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: ELEONOR'S PLACE 2	FACILITY NUMBER: 306005866
	VISIT DATE: 09/19/2022

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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present in the backyard for the enjoyment of residents and visitors. The perimeter gate on the side of the facility is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory regarding staff associations is being issued. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC809 (FAS) - (06/04)

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