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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006036
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:03:56 PM

Document Has Been Signed on 10/19/2021 03:03 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:SOCAL EMPOWERED LLCFACILITY NUMBER:
306006036
ADMINISTRATOR:PERRAIE, JAMESFACILITY TYPE:
772
ADDRESS:23671 BRASILIATELEPHONE:
(888) 630-3860
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
10/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:James Perraie, Devon WaytTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the Pre-licensing inspection for the facility. LPA was greeted and granted entry by the Administrator James Perraie and compliance specialist Devon Wayt. LPA inspected the facility with the Administrator and compliance officer. Facility is a Social Rehabilitation Facility, capacity is for 6 ambulatory clients. Application was submitted to the Agency (CCL) on 06/28/2021. Facility phone number is 949-701-3551. LPA observed the following: Structure. Facility is a two story home with 4 bedrooms, the down stairs bedroom is being used as an office. Facility has an attached 3 car garage. One portion of the garage has been converted into a room. Fire inspection states the garage room can only be used for storage. Backyard. There is a backyard with a pool. The pool is fenced and the gate is secured. The pool fencing meets the regulation requirements. The backyard has two separate seating areas with shade for clients. The exit gate leaving the backyard is operational. LPA did not observe any obstacles or hazards in the backyard. Clients Bedrooms. The client bedrooms are spacious and will easily accommodate the client's belongings. All bedrooms had the required furnishings. All beds had new linens. Downstairs Living area & Dining room. LPA observed new furniture in the living room, dining room and den/family room which located next to the kitchen. LPA observed the fireplace in the den/family room has a metal screen. The fireplace gas line has been capped. Bathrooms, all 3 are clean, faucets and toilets were operational. Linens & Hygiene Supplies. new linens and towels were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. Facility does not have clients at this time. LPA observed 60 day supply of emergency food and water on hand. Carbon Monoxide & Smoke Detectors & Fire Extinguishers were observed. All fire extinguishers were fully charged. Smoke detector/carbon monoxide detectors tested operational. Appliances. New Stove and microwave oven have been installed. LPA observed the stove lit unassisted. Knives: will be kept locked in the garage. Toxins: LPA observed chemicals locked in a garage cabinet. Water temperature measured 105 degrees. Medication cabinet is locked in the garage. First-Aid Kit & Activity Supplies. observed and available. First Aid kit had all the required elements Resident & Staff Files currently there is no staff and no clients, no files reviewed. Fire clearance was approved by Orange County Fire Authority Inspector Michael Longbardo on 7/23/2021. Continued on LIC 809C.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306006036
VISIT DATE: 10/19/2021
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During the visit LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the Central Applications Unit (CAU) supervisor in Sacramento. Component III was waived during the visit due to applicant is a current licensee for a licensed facility and in compliance status, supervisor approved. Facility is ready to be licensed. An exit interview was conducted and a copy of this report, LIC809, was explained and provided to applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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