306006095-4-12-2022-22-AS-KSGH-CDERRD-20220412131459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:15:07 PM

Document Has Been Signed on 04/12/2022 01:15 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:	EPIC ASSISTANCE CARE HOME		FACILITY NUMBER:	306006095
ADMINISTRATOR:	MESDJIAN, LIZA		FACILITY TYPE:	740
ADDRESS:	26751 CARRETAS DRIVE		TELEPHONE:	(818) 220-0282
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Liza Mesdjian, Licensee		TIME COMPLETED:	01:30 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting the pre-licensing verifications required for a change of ownership. At approximately 12:00pm, LPA was greeted upon arrival by prospective licensee Liza Mesdjian and granted entry. Facility is a one-story house with an attached garage. Six (6) bedrooms are assigned to residents and one (1) bedroom is assigned to staff. The current census is six (6) with two (2) residents currently under hospice care. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. LPA accompanied by administrator started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents. The bathrooms used by residents are equipped with non-slip mats and grab bars and displayed hand washing signs. Hot water is measured to be 106 degrees in the kitchen and 105 degrees in one of the bathrooms. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as one carbon monoxide detector in a central hallway. The exterior of the physical plant is free of clutter and debris. Perimeter gates are self-latching and easy to open in the eventuality of an evacuation. An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply. Weekly nutrition plans are displayed in the kitchen. A sufficient supply of PPE is also observed. Cleaning supplies and toxics are stored securely under the sink. Medication assigned to each resident is centrally stored in bubble packs and locked. Staff and resident files are stored on the premises. Two resident files are observed to include all required documentation, with some documents dated beyond the required updating period. Licensee is informed of the need to conduct emergency contact and physician reports updates annually once licensed. CONTINUED IN LIC809C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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: EPIC ASSISTANCE CARE HOME	FACILITY NUMBER: 306006095
	VISIT DATE: 04/12/2022

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CONTINUED FROM LIC809

Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted to Community Care Licensing (CCL) as well.

In order to be in compliance to be licensed, the prospective licensee will need to address the following items:
- Two missing locks needed to secure the cabinets where cleaning supplies are stored in the laundry room will need to be replaced. All toxics including room deodorizers need to be securely stored.
- A screen will need to be installed in front of the dining room fireplace
- Night lights will need to be installed in the bedrooms and hallways to allow secure access to the bathrooms at night.
- Supplements, medication and potential toxic substances stored in the staff bedroom will need to be secured either within a cabinet or by allowing access to the room to be locked by staff.

The facility is not yet ready to be licensed, but will be once the items have been successfully corrected. LPA conducted the Component III orientation with the prospective licensee during the visit. An exit interview and a copy of the report were provided at the time of the exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC809 (FAS) - (06/04)

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