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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 07/14/2023
Date Signed: 07/14/2023 04:33:24 PM


Document Has Been Signed on 07/14/2023 04:33 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:EPIC ASSISTANCE CARE HOMEFACILITY NUMBER:
306006095
ADMINISTRATOR:MESDJIAN, LIZAFACILITY TYPE:
740
ADDRESS:26751 CARRETAS DRIVETELEPHONE:
(818) 220-0282
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 1DATE:
07/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Liza Mesdjian, AdministratorTIME COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of documenting deficiencies observed during the initial investigation of the allegations in complaint reference #22-AS-20230217143103. LPA was greeted and granted entry by caregiving staff and spoke with administrator by telephone.

During the investigation, it became apparent that at least two caregivers and one resident at the facility tested positive for COVID during the month of November 2022. Facility staff did not report the outbreak to the Department as required.

Based on observation, interviews and records reviewed at the facility, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted via telephone and a copy of the report along with appeal rights was provided and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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Document Has Been Signed on 07/14/2023 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: EPIC ASSISTANCE CARE HOME
FACILITY NUMBER: 306006095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87211(a)(2)

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The California Code of Regulations Section 87211(a)(2) on Reporting Requirements states that: "Occurrences, such as epidemic outbreaks (...) shall be reported within 24 hours (...) to the licensing agency". This requirement is not met as evidenced by:
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Licensee to review applicable regulations and conduct staff training on Reporting Requirements.
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Based on interviews conducted and records reviewed, multiple staff members and resident contracted COVID in November 2022 and were not reported to the Department. This constitutes a potential risk to the health, welfare and personal rights of the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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