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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005924
Report Date: 04/12/2022
Date Signed: 04/12/2022 10:47:37 AM


Document Has Been Signed on 04/12/2022 10:47 AM - 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:NEW HOME SENIOR CARE 4FACILITY NUMBER:
306005924
ADMINISTRATOR:SCHOTT, BRIANFACILITY TYPE:
740
ADDRESS:24516 SATURNA DRIVETELEPHONE:
(626) 864-9955
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brian Schott, Licensee
Fe Szalonek, Administrator
Jill Jumalon, caregiver
Allan Diamida, house manager		TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Jill Jumalon, caregiver after explaining the purpose of the visit and being subject to the COVID-19 screening procedure in place. Administrator and licensee were called and arrived later to assist with the visit.

At approximately 9:45am, LPA accompanied by administrator toured the inside and outside of the facility. There are currently six (6) residents in care, with one (1) resident currently on hospice. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. The five (5) bedrooms assigned to residents include all necessary components. Bathrooms are equipped with grab bars, slip mats and hand-washing signs. Facility appears to be clean, sanitary and free of odors in all areas.

Sharp instruments are kept in a cabinet secured by a magnetic lock. Cleaning supplies and toxic substances are securely stored in the attached garage, with a locked access door. LPA observed the facility has COVID-19 Precautions posters and required department postings. The Administrator's license is up to date and posted in a central location. Facility has an adequate supply of PPE. A LIC808 Mitigation Plan has been submitted and approved on 07/23/2021.

LPA observed a sufficient supply of food and water as well as a dedicated emergency supply of food and water stored separately. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard. The perimeter gates are self-latching and can easily be opened in an evacuation.

Based on the observations made during the visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory regarding the staff's association status is being issued. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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