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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005934
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:35:44 PM


Document Has Been Signed on 05/12/2022 02:35 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
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) 861-1124
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Administrators Brian Schott and Fe SzalonekTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Marin and Celine De Perio made an unannounced required annual inspection to this facility. LPAs met with Administrator (ADs) Brian Schott and Fe Szalonek; and stated the purpose of this visit.

This facility is a single level structure and licensed for 6 non-ambulatory and with hospice waiver for six. For this visit, there was one resident under hospice care.

LPAs Marin and De Perio toured the interior and exterior portions of the facility. There were four private and one shared resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Paging system was observed to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 114 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non-perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit door was self closing and self latching. LPAs reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPAs also discussed the requirements for requesting an exemption for a bedroom furniture.

No citation was issued during this visit.

LPAs Marin and De Perio conducted an exit interview with ADs Schott and Szalonek; and 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: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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