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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005898
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:33:52 PM


Document Has Been Signed on 02/17/2022 04:33 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 3FACILITY NUMBER:
306005898
ADMINISTRATOR:AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:26711 VALPARISO DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Mark CruzTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Administrator Mark Cruz. LPA explained the reason for the visit. LPA and Administrator toured the facility. LPA reviewed the facility roster on Guardian. 2 out of 5 staff were not associated to the facility. LPA informed the Administrator of the civil penalty and citation for the violation. LPA informed the Administrator the staff would not be allowed to be at the facility until they have been associated to the facility, Administrator stated they understood. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all the resident rooms were clean and organized and had the required furnishings. LPA observed both bathrooms were clean and organized and operational. Smoke detectors tested operational. The living room had a TV and chairs and couches for the residents to sit. LPA observed the fireplace is screened. The kitchen is clean and organized. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. The medications are kept locked in a closet. The knives are kept locked under the kitchen sink. LPA and administrator toured the backyard. LPA observed a covered patio with a seating area for residents. No bodies of water observed. The exit gate is latched and operational. The exit gate is self closing. No obstacles or hazards observed. Facility mitigation plan is pending review. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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Document Has Been Signed on 02/17/2022 04:33 PM - It Cannot Be Edited

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 3
FACILITY NUMBER: 306005898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(2)
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall;
(2) request a transfer of a criminal record clearance as specified in Section 87355(c) or...

This requirement is not met as evidenced by: LPA observed through record review and the use of the Guardian website that Staff 1 and Staff 2 are not associated to the facility.
Deficient Practice Statement
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Based on observation in Guardian and record review the licensee did not comply with the section cited above in 2 out of 5 staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee states the 2 staff members will be associated to the facility and all future staff will be associated to the facility prior to starting employment. LPA will review Guardian to verifiy the staff have been associated.
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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2