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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006171
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:34:20 PM

Document Has Been Signed on 01/14/2025 01:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ABLELIGHT, INC. -- PAPAGAYOFACILITY NUMBER:
306006171
ADMINISTRATOR/
DIRECTOR:		KUM, JENNIFERFACILITY TYPE:
735
ADDRESS:26372 PAPAGAYO DRTELEPHONE:
(707) 685-7067
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 3DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Maria Amedo- Adminstrator
Michelle Torres- Lead Staff		TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was allowed entry by Lead Staff (LS) Michelle Torres after explaining the purpose of the visit. Administrator (Admin) Maria Amedo arrived upon notification of LPA's arrival.

The facility offers a service level 4G. The facility is a two story structure in a residential neighborhood. Facility is licensed to operate four (4) non ambulatory clients from age ranges 18-59. LPA observed three clients getting ready to leave for the day with one staff present during today's visit.

LPA toured the physical plant. There are four client bedrooms with two bedrooms on each floor and three client bathrooms. LPA observed all common areas which includes the office on the second floor and two car garage which doubled as a laundry area. Based on LPA's observation, the facility was not clean and sanitary. The kitchen pantry and refrigerator required a deep cleaning as there were evidence of food particles and stains. Holes were observed on the walls and bathroom door. There were dirt stains on the carpeted staircase that require a deep cleaning. A tear was present on the sliding door screen on the first floor. The client bedrooms were appropriately furnished and had the required components. Beds and extra supply of linens were observed to be in good condition, adequate lighting was provided, and sufficient storage space for each clients' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 111.9, 111.4, and 111.3 degrees Fahrenheit. All bathrooms maintained soap and toilet/paper towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. Toxins, disinfectants, sharps, and medications were also secured and inaccessible. There is a minimum of two day perishable food and one week of non-perishable food available.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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Document Has Been Signed on 01/14/2025 01:34 PM - It Cannot Be Edited


Created By: Jessica Cho On 01/14/2025 at 11:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ABLELIGHT, INC. -- PAPAGAYO
FACILITY NUMBER: 306006171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the carpeted staircase accumulated stains, holes around the facility, a tear on the screen, and food debris/stains in the kitchen pantry and refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator stated that they will correct the above items by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ABLELIGHT, INC. -- PAPAGAYO
FACILITY NUMBER: 306006171
VISIT DATE: 01/14/2025
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The facility is maintained at a comfortable temperature. The fire extinguishers were mounted and serviced on December 19, 2024. The dual functioning smoke/carbon monoxide detectors were tested by Pacific Signaling Systems on January 3, 2025 which passed per the semi-annual inspection report. LPA toured the outside grounds. The outdoor passageways are clear and free of obstructions. The exit gates were self-closing and self-latching. The facility land line, 949-830-8629, was tested and remains available. LPA observed sufficient emergency food/water stored in the garage. Power outage supplies are deemed insufficient in the event of an emergency per inspection of the two emergency backpacks. Emergency drills are conducted quarterly. LPA observed the first aid kit and manual. Also present in the facility vehicle was an unopened first aid kit and fire extinguisher. The administrator's certificate for Maria Amedo is effective January 4, 2025.

LPA conducted an audit of three client and two staff files. Discrepancies noted on the staff files as there were two missing documents. Medications and Personal and Incidental (P&I) Funds were audited. No discrepancies noted. LPA interviewed one staff. No client interviews were conducted as clients were not present at the time of the interview.

The following items were consulted with the Admin and LS: to patch/repair holes, replace screen, deep clean pantry, refrigerator, and carpeted stair case, complete missing personnel records as discussed, review/amend/submit the Emergency Disaster Plan (LIC610E). Also reminded was to ensure timely payment of the annual licensing fee due February 17, 2025.

Based on observations made during today's visit, a deficiency is being cited. Advisories are also being issued.

An exit interview was conducted with Administrator Maria Amedo and Lead Staff Michelle Torres, and a copy of this report including the LIC809D, LIC9102s, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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