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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006136
Report Date: 10/04/2022
Date Signed: 10/04/2022 11:43:06 AM


Document Has Been Signed on 10/04/2022 11:43 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:SOLACE SENIOR CARE HOMEFACILITY NUMBER:
306006136
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:25752 PERICLES STREETTELEPHONE:
(949) 215-1945
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
10/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Minerva SansanoTIME COMPLETED:
12:00 PM
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On 10/04/2022 at 9:56am, Licensing Program Analyst (LPA) Jessica Cho made an announced visit for a pre-licensing evaluation. LPA met with Applicant/Licensee Minerva Sansano. The facility has six bedrooms and two full bathrooms. This is a single story facility with a two car garage. The inspection is as follows:

A fire clearance was granted on March 8, 2022 for a capacity of 6 residents of which 5 are non-ambulatory and 1 is bedridden. The Applicant has requested a hospice waiver of 6 on the initial application on January 10, 2022.



LPA toured the interior and exterior of the facility including all resident bedrooms and bathrooms. The hot water temperature was tested in the resident bathrooms and observed to at 116.6 degrees Fahrenheit in Bathroom #1 and 114.9 degrees Fahrenheit in Bathroom #2. One fire extinguisher was mounted and charged and was last serviced on January 14, 2022. Smoke detectors were centrally wired throughout and have been checked by the fire department. Carbon monoxide detectors are operational including auditory devices. There is sufficient supply of linens, incontinence, and PPEs.

The kitchen area was checked, clean/sanitary, and in good repair. There were non-perishable, perishable, and emergency food and water supplies. There was one locked cabinet for medications in the kitchen which included a first aid kit. All cleaning equipments were stored in the laundry room. Both exit gates were self-closing and self-latching. There was sufficient seating under a patio lattice. LPA observed the food menu, activity calendars, theft and loss policy, admission agreement, and emergency plans were posted. There is a Complaint Poster (PUB475) and the Ombudsman Poster in the entry way.


Continued LIC809-C...
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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: SOLACE SENIOR CARE HOME
FACILITY NUMBER: 306006136
VISIT DATE: 10/04/2022
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Component III was waived because Applicant has other licensed facilities and has already completed Component III.

It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau. An exit interview was conducted, and a copy of this report was given to Administrator Minerva Sansano.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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