306006031-9-16-2022-22-AS-JCHO-CJBQPL-20220916122055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006031
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:21:05 PM

Document Has Been Signed on 09/16/2022 12:21 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:	PORT MINOA		FACILITY NUMBER:	306006031
ADMINISTRATOR:	ROCHE, RYAN		FACILITY TYPE:	740
ADDRESS:	25601 MINOA DRIVE		TELEPHONE:	(949) 916-9228
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:52 AM
MET WITH:	Ryan Roche, Scott Messick		TIME COMPLETED:	12:35 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 09/16/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Port Minoa. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 10:52am, LPA Cho was allowed entry by Licensee/Administrator (Admin) Ryan Roche after completing the Coronavirus 2019 (COVID-19) screening procedure. Co-Licensee/Administrator Scott Messick, Care Staffs Alexander David, Yadira Loza, and America Mendoza were present at the facility. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) did not meet the size regulation and observed the poster in the size of 8.5" X 14." The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. There are currently five residents living in the facility of which none are receiving hospice care. The Administrator's Certificate for Ryan Roche and Scott Messick expires on 12/01/23. Around 11:05am, LPA Cho conducted a tour of the physical plant along with Admins Roche and Messick. The single story home consists of five resident bedrooms and two resident bathrooms. There is one staff bedroom. The facility also has a living room, family room, dining area, kitchen, laundry room, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 110.1 degrees Fahrenheit in the Bathroom #1 and 109.5 degrees Fahrenheit in Bathroom #2.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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: PORT MINOA	FACILITY NUMBER: 306006031
	VISIT DATE: 09/16/2022

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LPA Cho inspected the kitchen along with Admins Roche and Messick. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components except the first aid manual, and the facility had sufficient PPEs. Facility reviewed the infection control plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides iPads and laptop upon request.

LPA Cho reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Licensees/Administrators Ryan Roche and Scott Messick, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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