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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005965
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:54:14 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:OHANA BOARD AND CAREFACILITY NUMBER:
306005965
ADMINISTRATOR:UJIMORI, TROYFACILITY TYPE:
740
ADDRESS:25422 PACIFICA AVETELEPHONE:
(949) 302-6034
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 2DATE:
10/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Troy UjimoriTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Albert Marin made an announced visit to this facility to conduct pre-licensing inspection and Component III orientation LPA met with Licensee/ Administrator (AD) Troy Ujimori and stated the purpose of this visit.

On March 31, 2021, The Orange County Fire Authority granted fire clearance of six non-ambulatory to this two-level structure.

LPA Marin conducted a tour in the interior and exterior portions of the facility with AD Ujimori There were two residents in care and one staff member on the floor. There were six resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were tested to be operational. LPA observed bell in each room. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 108 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. First aid kit was in place. Fire extinguisher was mounted and charged. LPA observed required posters were in place. For the exterior portion, facility had outside furniture in good repair, and grounds were free of tripping hazards. Side exit doors were self-closing and self-latching.

LPA conducted Component III Orientation with Licensee/ Administrator Troy Ujimori.

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

Prelicensing visit and Component III Orientation are now complete. LPA Marin will inform and provide a copy of this report to Centralized Applications Bureau for final determination.

LPA Marin conducted an exit interview with AD Troy Ujimori. ; 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: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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