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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005866
Report Date: 11/20/2024
Date Signed: 11/20/2024 12:39:24 PM

Document Has Been Signed on 11/20/2024 12:39 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:ELEONOR'S PLACE 2FACILITY NUMBER:
306005866
ADMINISTRATOR/
DIRECTOR:		AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:24772 ARGUS DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Mark Ryan Cruz, Administrator
Darryl Avendano, Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an unannounced visit to conduct the required 1-year inspection. LPAs were greeted and granted entry by caregiving staff. Administrators Daryll Avendano and Mark Ryan Cruz were notified via telephone and later arrived to assist with the inspection.

There are currently five (5) residents in care, one (1) of which is receiving hospice care. LPAs observed residents participating in activities in the facility’s common areas and relaxing in their respective bedrooms. At approximately 9:30am, LPAs accompanied by Administrator toured the physical plant. The facility is a one-story house with an attached garage. The facility has five (5) resident bedrooms, one (1) of which is shared, one (1) staff bedroom, and two (2) bathrooms which are shared. The four (4) individual and one (1) shared bedroom appeared clean and spacious. LPAs observed one (1) of the five (5) resident bedrooms had a gap between the glass sliding door. LPAs observed all the resident bedrooms has the required furnishings. Resident bathrooms appear clean and sanitary. Bathrooms were equipped with grab bars and non-slip mats. Hot water temperature measured between 106.9 and 107.2 degrees Fahrenheit.

LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. LPAs observed knives locked in a lock box inside a locked kitchen cabinet. A fire extinguisher is located inside the kitchen which was observed to be charged and serviced as of April, 2024. LPAs tested the dual smoke/carbon monoxide detector which tested operational. The centrally stored medication is located in a locked closet next to the entrance door. The attached garage is inaccessible to residents and is used for storage and for laundry. Cleaning supplies are located in the garage. LPAs observed the facility has an emergency food and water supply which is also stored in the garage.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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Document Has Been Signed on 11/20/2024 12:39 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/20/2024 at 11:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELEONOR'S PLACE 2
FACILITY NUMBER: 306005866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and resident interview, the licensee did not comply with the section cited above as one sliding glass door was observed to have a significant gap letting cold air inside the room. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee obtained adhesive insulation material and repaired the sliding glass door during the present visit. Repair confirmed. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELEONOR'S PLACE 2
FACILITY NUMBER: 306005866
VISIT DATE: 11/20/2024
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CONTINUED FROM LIC809
LPAs and administrator toured the outside of the facility and observed it to be free of obstructions. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the southside of the facility is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed five (5) of five (5) resident records. No discrepancies were observed. LPAs reviewed five (5) of five (5) resident medication records. No discrepancies were observed. LPAs interviewed two (2) residents. LPAs reviewed three (3) staff records. No discrepancies were observed. All staff are background cleared and associated to the facility.

Based on the observations made during today’s visit, there is 1 type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is also being provided regarding a resident’s admission agreement. This report was reviewed with facility Administrator and a copy of this report was provided. Appeal rights were provided to the Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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