306005924-4-19-2021-22-AS-MBAT-C28QUS-20210419122912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005924
Report Date: 04/19/2021
Date Signed: 04/19/2021 12:30:59 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:	NEW HOME SENIOR CARE 4		FACILITY NUMBER:	306005924
ADMINISTRATOR:	SCHOTT, BRIAN		FACILITY TYPE:	740
ADDRESS:	24516 SATURNA DRIVE		TELEPHONE:	(626) 864-9955
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	04/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator (Ad) Brian Schott		TIME COMPLETED:	11:30 AM

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 10:00 AM 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 Administrator (AD) Brian Schott. The facility contains 6 bedrooms with 4 full bathrooms, is a single-story building with an attached 2-car garage. This pre-licensing inspection was due to a change in ownership and the facility had four (4) residents in care at the time of this visit. The inspection was as follows: Physical Plant: At 10:10 AM LPA conducted the virtual inspection and toured the inside and outside of this facility with AD Schott, 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 gates were observed to be self-closing and self-latching with alarms installed. The kitchen was clean, and knives were stored in a locked cabinet. There were smoke detectors installed throughout common areas as well as all of the bedrooms which are centrally wired and observed to be in good operation. LPA observed that there were alarms installed on all of the exit doors that were observed to be functional. Fire extinguishers were located in the kitchen and was observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked cabinet in dining room area where the complete first aid kit was located as well. Bedrooms: Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions and equipped with functional alarms. 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: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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: NEW HOME SENIOR CARE 4	FACILITY NUMBER: 306005924
	VISIT DATE: 04/19/2021

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 114.5, 111.4, 115.1 and 116.0 degrees F. Faucets were in good operation, hand washing signs were posted and the facility also equipped the toilets with handled, raised commodes.

Supplies:
There was a sufficient supply of paper products, cleaning supplies, hygiene products and linens.

Food Service:
The facility met the 2-day perishable and 7-day nonperishable on hand food supply as LPA observed fresh fruit, canned goods, bread, dairy products, eggs, frozen meats and cereals in both the kitchen and garage. The facility had two (2) refrigerators, a freezer and food stored in the kitchen and in the garage. The food was observed to be stored appropriately and away from cleaning supplies.

Records:
Staff and Resident files were kept at the facility and available for review. LPA reviewed one (1) resident file and one (1) staff file and observed them to be in good order.

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

Component III Orientation was waived due to the facility is being re-licensed and the Administrator has been serving in this capacity for several years over this facility. Administrator stated that the facility does advertise for dementia care.

An exit interview was conducted with the Administrator and a 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: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC809 (FAS) - (06/04)

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