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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006108
Report Date: 03/28/2022
Date Signed: 03/28/2022 11:31:55 AM


Document Has Been Signed on 03/28/2022 11:31 AM - 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:OHANA CARE 3FACILITY NUMBER:
306006108
ADMINISTRATOR:FISK, RYAN; FISK, BRIGITTEFACILITY TYPE:
740
ADDRESS:24362 AUGUSTIN ST.TELEPHONE:
(949) 989-1975
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ryan Fisk, Administrator
Brigitte Fisk, Administrator		TIME COMPLETED:
11:00 AM
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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 9:40am, LPA was greeted upon arrival by the current and prospective licensee Ryan Fisk and Brigitte Fisk and granted entry. Facility is a one-story house with an attached garage. Four (4) bedrooms are assigned to residents. No residents are currently under care at the moment as light renovations will be performed shortly.

LPA Saborit-Guasch started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents. The two (2) bathrooms used by residents are equipped with non-slip mats and grab bars. The hot water temperature is measured to be 105 degrees in the kitchen and 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 carbon monoxide detectors in hallways and in the main area. The exterior of the physical plant is also free of clutter and debris. No gates are present at the sides of the house on the noted evacuation routes. A swimming pool is observed on the premises and noted to be adequately fenced and locked as per the approved fire clearance.

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 and rotated between the facilities operated by licensee. A sufficient supply of PPE is also stored in the medication cabinet. Cleaning supplies and toxics are stored in a cabinet in the laundry room which is always kept locked by a combination doorknob. Medication assigned to each client is centrally stored in bubble packs and locked. Staff and resident files are stored on the premises.

(Continued on LIC809C form)
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: OHANA CARE 3
FACILITY NUMBER: 306006108
VISIT DATE: 03/28/2022
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Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted to Community Care Licensing (CCL).

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. As the prospective licensee already operates the facility under a different business name, the Component III has been waived. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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