<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005995
Report Date: 08/06/2024
Date Signed: 08/06/2024 12:41:38 PM


Document Has Been Signed on 08/06/2024 12:41 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HEYDAY SENIOR LIVING OF MISSION VIEJOFACILITY NUMBER:
306005995
ADMINISTRATOR:ALIM, JEROMEFACILITY TYPE:
740
ADDRESS:26751 VIA GRANDETELEPHONE:
(949) 558-4478
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Veahlou Daelto, AdministratorTIME COMPLETED:
12:45 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the inspection. Administrator Vealhou Daelto was also present and able to assist with the visit. The facility is currently undergoing a change of ownership with a pending application under license #306006563.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a two-story home. The upper level is not accessible to residents and is used as a living quarter for relatives of the licensee, which were verified to be associated. There are six private bedrooms and two shared bathrooms in addition to the facility's common living areas. All resident bedrooms have the required furnishing, bathrooms are equipped with grab bars and slip mats. LPA observed all beds have linens and blankets.

The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently four residents admitted to the facility with one resident pending discharge. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within the required range in three locations throughout the house. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire drills are conducted quarterly. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Smoke and carbon monoxide detectors tested operational. One fire extinguisher present is observed to be fully charged with proof of up-to-date maintenance. Sharp items, cleaning supplies and medications were confirmed to be inaccessible throughout the physical plant.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HEYDAY SENIOR LIVING OF MISSION VIEJO
FACILITY NUMBER: 306005995
VISIT DATE: 08/06/2024
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
26
27
28
29
30
31
32
CONTINUED FROM FROM LIC809
The medication central storage was also observed to be secure and was reviewed for accuracy during the visit. LPA reviewed four resident files along with six staff files. Two staff and one resident interviews were conducted during the annual.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2