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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006031
Report Date: 09/14/2021
Date Signed: 09/14/2021 01:33:17 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:PORT MINOAFACILITY NUMBER:
306006031
ADMINISTRATOR:ROCHE, RYANFACILITY TYPE:
740
ADDRESS:25601 MINOA DRIVETELEPHONE:
(949) 413-3289
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
09/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrators (ADs) Ryan Roche and Scott MessickTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPAs) Albert Marin, Jerome Haley and Beverly Thompson-Gracia made an announced visit to this facility to conduct a pre-licensing inspection and Component III orientation. LPAs met with Administrators (ADs) Ryan Roche and Scott Messick and stated the purpose of the visit.

On July 19, 2021, The Orange County Fire Authority granted the fire clearance of 5 non-ambulatory and 1 bedridden for this single structure.

About 9:55 AM, LPAs Marin, Haley and Thompson-Gracia were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPAs toured the interior and exterior portions of the facility. There were four residents in care and two staff members on the floor. Currently there were five private 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. Call system was in place and tested to be operational. Bathrooms were observed to be in good repair, provided with grab bars and nonskid floor mats. Hot water was measured at 106 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. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-closing.

LPA Marin conducted the Component III Orientation with ADs Ryan Roche and Scott Messick.

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

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

LPA Marin conducted an exit interview with ADs Ryan Roche and Scott Messick 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: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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