306006238-6-20-2023-22-AS-LMAZ-CSYRWS-20230620132337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006238
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:24:17 PM

Document Has Been Signed on 06/20/2023 01:24 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:	CAMINO HILLS CARE HOME 1		FACILITY NUMBER:	306006238
ADMINISTRATOR:	ANG, MERCEDITA		FACILITY TYPE:	740
ADDRESS:	2927 BONANZA		TELEPHONE:	(949) 369-8390
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	6	CENSUS: 6	DATE:	06/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mercedita Ang & Maricris Lafiguera		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to this facility for the purpose of completing a Pre-licensing evaluation. LPA met with Applicants Mercedita Ang & Maricris Lafiguera. This is a Change of Ownership with 6 Residents present during today's visit. The Application was submitted to Community Care Licensing on 06/20/2022. Facility is a one story, 6 bedroom, 3 full and 2 1/2 bathrooms home with an attached 2 car garage. There is no bedroom for caregivers as the facility will employ 24-hour awake staff. The Fire Extinguisher was located in the dining area adjacent to the kitchen. Smoke detectors are hardwired throughout the facility and are equipped with carbon monoxide detection. The facility is equipped with Fire Sprinklers throughout the facility. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. Bedrooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms have wash basin and walk in showers. Linen supply is ample for the residents in care. Facility has a two day supply of perishables and seven day of non-perishable food. Stove, oven, refrigerator, dishwasher, microwave, washer, and dryer are clean and operational. There is a locked area for medications in the hallway closet adjacent to the entry way. The garage contained locked cabinets for storing toxins, detergents, cleaning supplies, gardening supplies, tools, and is to be used for storage only. Beds were made with appropriate linens. Hot water in bathrooms is within regulatory requirements. First Aid Kit observed contained all required items. The facility has Wellness program, music therapy and pet therapy. Facility has a shaded area in the front and side of the facility with table and chairs to accommodate residents and visitors. Side exit gates are unlocked. The Component III was waived as Applicant is an existing Licensee/Administrator for other existing facility. (continued on LIC809C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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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: CAMINO HILLS CARE HOME 1	FACILITY NUMBER: 306006238
	VISIT DATE: 06/20/2023

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A Fire Clearance was granted on 01/17/2023 for 2 non-Ambulatory, 2 Ambulatory and 2 bedridden residents with the following special conditions shown on the approved floor plan: bedrooms #1 and #2 for Non-Ambulatory, bedrooms #3 and #4 for Ambulatory and bedrooms #5 and #6 for Bedridden.

During today's visit, LPA noted ALL residents currently residing at the facility are non-Ambulatory, of which 3 are receiving Hospice services. The Ambulatory rooms are being occupied by Residents receiving hospice services.

Current Facility (San Clemente Care Home-306005174) is licensed for 5 non-Ambulatory and 1 bedridden. There were no plans to move the current residents.

Applicant stated she can/will relocate 2 residents to her other facility prior to licensure if need be.

Applicant stated bedroom #1 and bedroom #2 were the designated bedridden rooms and was not aware of the change on the floor plan approved by the Orange County Fire Authority making bedroom #5 and 6 for bedridden.

LPA explained that clarification is needed before facility is ready for licensure based on inspection. LPA has contacted CAB. An exit interview was conducted and a copy of this report will be sent to email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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