306005869-2-18-2021-22-AS-MBAT-BYD45N-20210218174812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005869
Report Date: 02/18/2021
Date Signed: 02/18/2021 05:50:10 PM

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:	JJ ASSISTANCE HOME CARE		FACILITY NUMBER:	306005869
ADMINISTRATOR:	AZIZA, SIMONA		FACILITY TYPE:	740
ADDRESS:	23712 CORONEL DR		TELEPHONE:	(949) 587-1595
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS:	DATE:	02/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Applicant (AP) Simona Aziza		TIME COMPLETED:	03:00 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	At 1:00 PM, Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with Applicant (AP) Simona Aziza. The facility contains 7 bedrooms with 7 bathrooms, is a single-story building with a 2-car garage. At the time of this inspection, there were 6 residents that were observed to be clean and in clean clothes. LPA Barrett's observations during the physical plant inspection were as follows: Physical Plant: At 1:10 PM, LPA conducted the virtual inspection with AP and toured the inside and outside of this facility including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways and the backyard gate was observed to be self-closing and self-latching. The kitchen was observed to be clean and all appliances were operational. Sharps were stored under the sink in the locked cupboard. The smoke detectors were installed throughout common and bedrooms, were centrally wired, and observed to be in good operation. The carbon monoxide detector was located in the hallway, was tested and observed to be operational. LPA had AP test the alarms installed on all of the exit doors and they were observed to be functional. Fire extinguishers were located in the living room and in the garage. Both were observed to be appropriately charged and mounted. Centrally Stored medications were stored in the locked kitchen cupboard and were in good order. Bedrooms: Bedrooms were observed to have made beds appropriate closet space, dresser drawers, appropriate lighting and exit doors were free of obstructions with operational alert system. Continued on page 2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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: JJ ASSISTANCE HOME CARE	FACILITY NUMBER: 306005869
	VISIT DATE: 02/18/2021

NARRATIVE

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Continued from page 1.
Bathrooms:
Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures
from the faucets measured within regulation 105 and 120 degrees F. Toilets and sinks were clean and in good operation.

Laundry:
The washer and dryer were located in the locked garage..

Food Service:
The facility met the 2-day perishable and 7 day non-perishable food supply on hand.

Records:
Staff and Resident files were stored in a desk drawer located in the foyer. .

Administration:
LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-
Us-No” poster posted in the facility.

Activities:
LPA and AP discussed activities planned for the residents in the facility and LPA observed crafts, puzzles and
games for the residents.

Component III orientation:
The Component III Orientation conducted as well as a question/answer session for consultation.

Applicant stated that the facility does not plan to advertise for dementia care. This inspection has been completed and, based on the results of this inspection, this facility is recommended for licensure.

An exit interview was conducted with Applicant, Jessica Camacho, and a hard copy of this report was provided via email for Signatures

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC809 (FAS) - (06/04)

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