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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005934
Report Date: 06/07/2021
Date Signed: 06/07/2021 11:07:30 AM

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:ADULT CARE OC SATURNAFACILITY NUMBER:
306005934
ADMINISTRATOR:SCHOTT, BRIANFACILITY TYPE:
740
ADDRESS:24591 SATURNA DRIVETELEPHONE:
(626) 864-9955
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
06/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Licensee/ Administrator Brian SchottTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an announced prelicensing visit to this facility and met with Licensee and Administrator (AD) Brian Schott. LPA stated the purpose of this visit.

The facility is a single level structure. On May 14, 2021, The Orange County Fire Authority granted the fire clearance of six non-ambulatory. At 10 AM, LPA Marin conducted a tour of the interior and exterior portions of the facility. LPA observed two staff members and 4 residents in care. There were four private and one shared resident's rooms; and one staff room. Rooms were provided with linens adequate furniture, and adequate storage space. Hallway was provided with adequate light and kept free of tripping hazards. Three common bathrooms were observed to have grab bars and non-skid floor features. Hot water was measured from 110 to 114 degrees Fahrenheit. Smoke, carbon monoxide and auditory alarms were tested to be operational; and fire extinguisher was mounted and charged. Kitchen appeared clutter free. Sharp kitchen utensils, cleaning supplies, medications and facility files were kept accessible to facility staff only. Facility met the two-day perishable and seven-day non-perishable food stock requirements. LPA observed the posting requirements in place. Exterior features had adequate open space with furniture in good repair. Exterior exit gate was self-latching and self-closing. LPA Marin conducted Component III orientation with AD Schott.

For this visit, the facility was observed to be in substantial compliance with the Title 22 Division 6 of the California Code of Regulations.

AD Schott is NOT planning to advertise for Dementia Special Care Program.

The prelicensing and Component III orientation are now complete. LPA Marin will forward this report to the Centralized Applications Bureau for review.

LPA Marin conducted an exit interview with AD Schott. Copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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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