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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006143
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:03:26 PM

Document Has Been Signed on 08/30/2022 01:03 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:MENTAL HEALTH COLLECTIVE, THEFACILITY NUMBER:
306006143
ADMINISTRATOR:ROSENBAUM, GREGORYFACILITY TYPE:
772
ADDRESS:519 SANTA ANA AVE.TELEPHONE:
(888) 717-9555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: DATE:
08/30/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Greg Rosenbaum and Wendy GalvanTIME COMPLETED:
12:12 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator Greg Rosenbaum. Compliance Officer Wendy Galvan, Program Director Amber Labriola, and Administrative Assistant Jazmin Galvan were present as well. An initial application to operate a Social Rehabilitation Facility was received by CCL on 04/06/2022 for a capacity of six ambulatory clients. Covid signage was observed outside facility entrance and LPA observed the screening/ sanitizing station in the entrance of the facility. The home is currently operating as a sober living home.
LPA along with the management team toured the facility at 10:10 AM and observed the following:
Structure: Facility is a two story, 4 bedroom, 5 bathroom house with an attached garage and a grey concrete exterior. Second story has a separate casita with an outside entrance. Second story railings are monitored by video surveillance on management/ staff phones and computers . Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: Rooms will be single occupancy with the master being double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Second story master bedroom has locks on windows. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms as well as hand washing signs posted. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for clients in care. Emergency Phone Numbers and Exit Plan: Posted in common area of facility. Food Service: Facility does not have 2 day perishables and 7 day non-perishables present. LPA observed a posted menu and facility will have food delivered for lunch and dinner. Clients will prepare their own breakfast. LPA observed ample emergency food and water. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has secured area for toxins/ sharps garage. Water Temperature: Tested and CONT ON LIC 809C DATED 08/30/2022.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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: MENTAL HEALTH COLLECTIVE, THE
FACILITY NUMBER: 306006143
VISIT DATE: 08/30/2022
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recorded between 117.2 and 120.0 degrees F. in facility bathrooms. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication to be stored and locked in secured cabinet in the garage. Facility to use an electronic medication administration record. LPA observed the first aid manual Client & Staff File: Records to be are stored electronically. Reading Material, Games, and Equipment: Facility has an activity schedule posted in the facility. Activities to include outings in the community such as bowling, hiking, and shopping. Backyard: LPA observed a clean backyard with ample shaded seating for clients. Facility has a secured patio on the second floor. Fire Clearance: Approved for six ambulatory clients on 05/04/2022.

Component III waived during the visit. Facility participated in Component III on 08/19/2022.

Report to be forwarded to Central Applications Bureau for further review.







Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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