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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005940
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:04:21 PM


Document Has Been Signed on 12/01/2022 01:04 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 ACROPOLISFACILITY NUMBER:
306005940
ADMINISTRATOR:SZALONEK, FEFACILITY TYPE:
740
ADDRESS:24685 ACROPOLIS DRIVETELEPHONE:
(626) 864-9955
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Fe SzalonekTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Fe Szalonek was notified via telephone and arrived at the facility shortly after. AD Szalonek has a current administrators certificate that expires 10/21/23. There were five residents present during the visit.

At 10:40 AM LPA Haley and staff began the inspection at the entrance of the facility. LPA observed a screening station with face mask, hand sanitizer and a screening log book right next to the front door. Next to the screening station there's a locked medication closet with a first aid kit with all required elements, staff and resident record books on the shelf.

Resident bedrooms were clean, organized, and had all necessary requirements. The client bathroom were clean and organized. Hot water temperature was measured in the range of 108.1 degrees Fahrenheit and 111.5 degrees Fahrenheit in resident bathrooms. In the hallway cabinets near resident rooms 3 & 4 LPA observed plenty of clean linen in each cabinet.

The kitchen was clean and organized. LPA Haley observed knives and sharp objects locked in a drawer near the sink. All burners on the stove were operational. All hazardous chemicals were locked under the kitchen sink. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items. LPA Haley observed a fire extinguisher fully charged and mounted on the wall behind the microwave.

The garage had clear walkways free of clutter and tripping hazards. LPA observed two additional refrigerators with additional food items for the residents. There were three storage spaces: two spaces stored additional clothing and one space was for a supply of additional nonperishable food items.


Continued on LIC809C

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: ADULT CARE OC ACROPOLIS
FACILITY NUMBER: 306005940
VISIT DATE: 12/01/2022
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LPA Haley observed a emergency kit in a bucket on wheels, full of emergency supplies: nonperishable food items, a flash light/lamp, and emergency PPE supplies were some of the items observed. There was also a supply of emergency bottled water. In a corner of the garage LPA observed a section full of items being stored from the previous owner: washer, dryer, dishwasher, and various other items that were used for the facility. Staff stated they are waiting for the previous owner to pick up the items or they will be disposed of.

The backyard had clear walkways, free of tripping hazards. There was a side exit gate that was self closing and self latching. LPA Haley observed a shaded patio area with tables and chairs. In the backyard a small garden with bell peppers, onions, and chilies was observed.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report and LIC9102 was provided to Administrator Szalonek.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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