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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005898
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:08:28 PM

Document Has Been Signed on 04/25/2024 12:08 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 3FACILITY NUMBER:
306005898
ADMINISTRATOR/
DIRECTOR:		AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:26711 VALPARISO DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mark Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Mark Cruz was notified of the visit and arrived later to assist.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-story home with four resident bedrooms (two private and two shared), one staff room and one bathroom. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, three of which are receiving hospice care out of a waiver capacity of four. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files, two staff files as well as staff and resident interviews.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 12:08 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 04/25/2024 at 11:51 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 3
FACILITY NUMBER: 306005898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed during the facility visit, the licensee did not comply with the section cited above as one staff member present was observed to be cleared but not associated to the licensed location which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will associate all staff members scheduled at the licensed location in Guardian and provide proof of association to LPA before the plan of correction's due date.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the facility, the licensee did not comply with the section cited above in as the refrigerator was observed and measured to be at a temperature of 54F, which is above than the mandated 40F allowable per Title 22 regulations. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee to conduct a repair or replacement of the refrigerator and demonstrate an adequate storage temperature to LPA before the plan of correction's due date.
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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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