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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006143
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:32:20 AM

Document Has Been Signed on 12/07/2023 11:32 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
ORANGE COUNTY ASC, 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:
(949) 200-9821
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 5DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Greg Rosenbaum - Administrator TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Mental Health Technician Gavin Clifford. Director of Quality and Compliance Catherine Mann and Administrator Greg Rosenbaum joined the inspection during the tour.

Facility is a two story home with four bedroom, five bathroom, kitchen, living room, dining room, with an attached garage. Second story has a separate casita with an outside entrance. Second story railings are monitored by video surveillance on management/ staff phones and computers. LPA observed residents to be away from the facility at outside appointments. Shaded seating areas were observed in the front and backyard. The emergency exits on either side of the facility are unobstructed. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels. Hot water measured at 118 degrees Fahrenheit in the downstairs common bathroom, 116.2 degrees Fahrenheit in the bedroom 1 bathroom, 120 degrees Fahrenheit in the bedroom 2 bathroom, 118.4 degrees Fahrenheit in the upstairs shared bathroom and 116.7 degrees Fahrenheit in the upstairs detached bedroom. LPA observed facility has emergency food and water supply. LPA observed the fire extinguishers to be charged as indicated by the arrow pointing in the green area. Service tags indicate the extinguishers were last serviced on 2/14/2023. Medication for each resident is kept in locked cabinets in the garage. LPA reviewed three of the five client files, each contained required documentation. LPA reviewed three staff files, each contained required documentation LPA reviewed three out of the five clients' medication with the Administrator. Medication appears to be properly stored and administered. Facility has plenty of lounge space, books, exercise equipment, a piano and more for clients to utilize.

No deficiencies were noted during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2023
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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