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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006050
Report Date: 10/20/2021
Date Signed: 10/20/2021 04:21:04 PM

Document Has Been Signed on 10/20/2021 04:21 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:MIA RESIDENCEFACILITY NUMBER:
306006050
ADMINISTRATOR:ADOLFO, JEDFACILITY TYPE:
740
ADDRESS:25475 ADRIANA STTELEPHONE:
(949) 529-4130
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
10/20/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Giannina AdolfoTIME COMPLETED:
04:41 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 Giannina Adolfo. LPA inspected the facility with the Administrator. Facility is an RCFE, capacity is for 6 non-ambulatory residents of which 1 can be bedridden. Application was submitted to the Agency (CCL) on 08/04/2021. Facility phone number is 949-305-5259. LPA observed the following: Structure. Facility is a one story home with 7 bedrooms and 3 bathrooms. Facility has an attached 2 car garage. LPA did not observed the see something say something poster (pub 475) in the entrance of the facility. Backyard. The backyard has a patio with a seating area for residents. The exit gate leaving the backyard is operational. No bodies of water observed. LPA did not observe any obstacles or hazards in the backyard. Clients Bedrooms. The resident bedrooms are spacious and will easily accommodate the client's belongings. All bedrooms had the required furnishings. LPA observed the bedroom right off of the living room has a fireplace that is not screened. Living area & Dining room. LPA observed the living area and dining room have enough space to accommodate residents and visitors. Bathrooms, all 3 bathrooms are clean, faucets and toilets were operational. Water temperature measured, 115 degrees Fahrenheit in bathroom 1, 118 in bathroom 2 and 120 degrees in bathroom 3. Linens & Hygiene Supplies. new linens and towels were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed a two day perishable and seven day non-perishable food supply on hand. LPA observed the kitchen is clean and organized. Carbon Monoxide & Smoke Detectors & Fire Extinguishers were observed. All fire extinguishers were fully charged. Smoke detector/carbon monoxide detectors tested operational. Appliances. The stove and microwave oven are clean and operational. LPA observed the stove lit unassisted. Knives: are kept locked under the kitchen sink. Toxins: LPA observed chemicals locked under the kitchen sink. Medication cabinet is kept locked and located in the kitchen. First-Aid Kit & Activity Supplies. observed and available. First Aid kit had all the required elements Resident & Staff Files change of ownership, no files reviewed. Fire clearance was approved by Orange County Fire Authority Inspector Michael Longbardo on 9/16/2021. The following items must be corrected in order for the facility to be licensed; 1. Fireplace in the bedroom adjacent to the living room needs a fireplace screen.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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: MIA RESIDENCE
FACILITY NUMBER: 306006050
VISIT DATE: 10/20/2021
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2. The facility must post the see something say something poster (pub 475) in the entry way of the facility. The poster must be 20 X 26 inches. 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. LPA informed the applicant to contact the LPA within one week (10/27/21) to schedule the follow up pre-licensing visit. LPA explained that the items listed must be corrected in order to complete the pre-licensing inspection. Applicant stated she understood. 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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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