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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006036
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:27:25 PM

Document Has Been Signed on 10/06/2022 01:27 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: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:James PerraieTIME COMPLETED:
01:40 PM
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On 10/06/2022 at 11:40am, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Socal Empowered LLC. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 11:41am, LPA Cho met with Behavioral Health Technician (BHT) Carina Prado, Program Director (PD)/Charge Nurse Susan Kue, Clinical Director (CD) Lisa McCurry, and Case Manager (CM) Jonathon Ford who greeted LPA in the garage. All of the above names were only associated to Socal Empowered LLC #306005605 and were not associated to this facility. Per Admin's interview, Admin stated that this facility was not listed on Guardian. Admin logged on to Guardian, and LPA verified that only Socal Empowered LLC #306005605 was listed and confirmed all above staff were associated and fingerprint cleared. LPA provided consultation to contact Guardian and to register this facility #306006036. At 11:43am, LPA received a telephone call from Administrator (Admin) James Perraie, and LPA stated the purpose of the visit. LPA completed the Coronavirus 2019 (COVID-19) screening procedure with PD Kue. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors, clients, and staff on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility is licensed for six ambulatory clients, and there are currently four clients living in the facility.

At 12:05pm, LPA Cho conducted a tour of the physical plant along with PD Susan Kue. Administrator (Admin) James Perraie arrived at the facility around 12:05pm and also joined the tour. The two story home consists of three client bedrooms and bathrooms. The facility also has a formal living room, family room, dining room, kitchen, storage room, and an attached two-car garage with laundry which is also utilized as an office. The client bedrooms had the required furnishings. Client bathrooms were checked. Toilets and water faucets worked properly and showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306006036
VISIT DATE: 10/06/2022
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LPA Cho tested the hot water temperature in the client bathrooms and the temperature measured at 109.0 degrees Fahrenheit in the Bathroom #1, 100.1 degrees Fahrenheit in Bathroom #2, and 109.8 degrees Fahrenheit in Bathroom #3. LPA Cho inspected the kitchen along with PD Kue. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and last serviced on 09/19/2022. The smoke/carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients.

LPA Cho toured the outside grounds with PD Kue. LPA observed a swimming pool, and the gates were secured. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gate was self-closing and self-latching.



LPA Cho reviewed the Emergency and Disaster Plan for Social Rehabilitation Facilities (LIC610D). The facility did not have a current LIC610D form. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. LPA discussed the 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, and social rehabilitation facilities 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 a 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. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Administrator James Perraie, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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