306005965-9-6-2022-22-AS-KSGH-CHZV6H-20220906160933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005965
Report Date: 09/06/2022
Date Signed: 09/06/2022 04:09:47 PM

Document Has Been Signed on 09/06/2022 04:09 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:	OHANA BOARD AND CARE		FACILITY NUMBER:	306005965
ADMINISTRATOR:	UJIMORI, TROY		FACILITY TYPE:	740
ADDRESS:	25422 PACIFICA AVE		TELEPHONE:	(949) 807-2336
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	09/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Troy Ujimori, administrator Mila Ujimori, administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/06/2022 at 2:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by administrator Troy Ujimori and Mila Ujimori and explained the purpose of the visit. At approximately 2:45pm, LPA accompanied by administrators toured the physical plant of the facility. There are currently three (3) residents in care, all of which are receiving hospice care, which is in compliance with the terms of the approved hospice waiver. Residents are observed relaxing in the common areas or in their respective bedrooms and appear clean and well taken care of. The currently occupied bedrooms include all necessary components. A fifth bedroom is currently not in use and not furnished pending an upcoming admission for which a hospital bed will be installed by the resident's family. A sixth bedroom is currently not being used by residents but used as a staff bedroom and storage area. A Technical Advisory is issued by the LPA regarding the furnishing requirements. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments and cleaning supplies are stored securely with child-proofing mechanisms. The centrally stored medication is located in the entrance hallway in locked closet. A laundry area along with detergent are observed in the locked attached garage. LPA observed a sufficient supply of food and water present. LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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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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: OHANA BOARD AND CARE	FACILITY NUMBER: 306005965
	VISIT DATE: 09/06/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

The fire extinguisher present is mounted and charged but was inspected in March 2021, which means that it should have been reinspected in March 2022 at the latest. A Technical Violation is issued in regards to the fire extinguisher required maintenance. The posted administrator certificate is shown to be out-of-date, however administrator was able to provide documentation of the required coursework and valid certification during the visit. LPA provides consultation on the necessity to replace the posted document with a valid copy.

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present for the enjoyment of residents and visitors. The perimeter gates on both sides of the facility are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Violation advisory is issued in regard to the fire extinguisher's maintenance status. A Technical Advisory is additionally issued regarding the furnishing requirements in a residential care facility for the elderly. This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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