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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006150
Report Date: 06/20/2022
Date Signed: 06/20/2022 04:30:35 PM

Document Has Been Signed on 06/20/2022 04:30 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:CALIFORNIA CARE MENTAL HEALTHFACILITY NUMBER:
306006150
ADMINISTRATOR:BOUQUET, JASONFACILITY TYPE:
772
ADDRESS:25542 DANA MESA DRTELEPHONE:
(949) 291-3333
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 0DATE:
06/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Jason Bouquet, TIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection.. LPAs arrived at the facility and were greeted and granted entry by Applicant Jason Bouquet. An application to operate a Social Rehabilitation Facility for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 2/10/2022. Average client stay will be 30 days.

Structure:
The facility is a one story home with 3 client bedrooms, 2 bathrooms, living room, kitchen, staff office, and an attached two car garage. In the backyard there is a one room building that is a therapy room, this building was part of the fire clearance report and is approved for use as a therapy room. Facility telephone phone number is. 949-218-7104. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the staff office door. LPA observed there are door alarms on the front door and all exit doors. There is a back yard with 2 exit gates one on each the side of the house and they both have auditory alarms. LPAs tested each door alarm and they were all operational. There are two separate shaded seating areas in the backyard. No bodies of water observed. LPAs did not observe any obstacles or hazards in the backyard.

Client Bedrooms
The client’s bedroom are spacious and will easily accommodate their belongings. All client bedrooms had the required furnishings. LPAs observed all client beds had new linens and quilted blankets. LPAs observed all windows were screened.

Signal system
There is no signal system.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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 4
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
VISIT DATE: 06/20/2022
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Bedrooms Staff:
No staff will be living at the facility. The medication and sharp objects will be stored in the staff office that is kept locked and off limits to clients.

Bathrooms:
All bathrooms have working plumbing and were clean and organized. Hot water measured 116.9 degrees Fahrenheit in bathroom 1 which is a shared bathroom. Hot water measured 117.3 degrees Fahrenheit in bathroom 2 which is in the master bedroom.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week. Emergency food is stored in the kitchen.

Food Service:
There are no clients at this time. There isn't a supply of perishable and non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are clean and operational.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
VISIT DATE: 06/20/2022
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Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the supply closet.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked in a locker in the staff office. First aid kits are stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in office.

Pool/Jacuzzi & Pets:
No bodies of water in facility. No pets will be at the facility.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, art supplies and other recreational materials for the client’s use, stored in the living room.

Fire clearance:
Was approved by fire inspector Francisco Rivera Martinez of Orange County Fire Authority on 03/10/2022.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance and reporting requirements.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
VISIT DATE: 06/20/2022
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Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first client. This notification may be done by phone, email or fax. Accordingly, The Applicant was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. LPA informed the applicant's representative that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. Exit interview was conducted and a copy of this report was provided to applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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