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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005920
Report Date: 01/13/2025
Date Signed: 01/13/2025 05:19:24 PM

Document Has Been Signed on 01/13/2025 05:19 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:ALLIED PATHWAYS CARE HOME LLCFACILITY NUMBER:
306005920
ADMINISTRATOR/
DIRECTOR:		RAFAEL CARBAJALFACILITY TYPE:
735
ADDRESS:27341 LAS NIEVESTELEPHONE:
(661) 655-2929
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 4DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Laura Palomino- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the Care Inspection Tool. LPA met with Administrator Laura Palomino and explained the purpose of the visit.

The facility is a single story structure in a residential neighborhood. There are four client bedrooms and two client bathrooms. The facility offers a service level 4G.

LPA toured the interior and exterior of the facility. The facility appeared to be clean, sanitary, and operational. LPA observed the required department postings throughout the facility. There is a minimum of one week of non-perishable and two day perishable food available. The facility is maintained at a comfortable temperature. LPA observed medications are centrally stored in a locked cabinet in the medication office. LPA measured the hot water temperature which measured at 105.4 and 107.4 degrees Fahrenheit. All bathrooms were observed to have a supply of soap, toilet paper, and clean towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxins, cleaning solutions, and disinfectants are stored locked in the medication office. The facility maintains extra supply of clean linens. LPA inspected the clients' bedrooms which has sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedrooms. LPA toured the outside grounds and observed outdoor passageways are free of obstructions. The exit gate is self-closing and self-latching. LPA observed sufficient seating and shading. LPA observed the fire extinguisher was mounted, charged, and serviced on September 3, 2024. The auditory devices, carbon monoxide, and smoke detectors were tested and operational. LPA observed the required 'See Something, Say Something' (PUB475) poster posted on the door to the medication office.
The liability insurance is current. The facility land line, 949-305-2882, was tested and remains available.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ALLIED PATHWAYS CARE HOME LLC
FACILITY NUMBER: 306005920
VISIT DATE: 01/13/2025
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LPA conducted an audit of four clients' files and two personnel files. No discrepancies noted with the file review. LPA conducted two staff and three client interviews. Medications were audited. No discrepancies noted.

Based on the observations made during today's visit, no deficiency is being cited today. Advisories are being issued.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report including the LIC9102s were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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