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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006281
Report Date: 03/21/2023
Date Signed: 03/22/2023 06:51:28 AM


Document Has Been Signed on 03/22/2023 06:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PORT ARTEMIAFACILITY NUMBER:
306006281
ADMINISTRATOR:ROCHE, RYANFACILITY TYPE:
740
ADDRESS:2463 ARTEMIA AVENUETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ryan Roche & Scott MessickTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA's) Lydia Martinez and Dwayne Mason Jr. conducted this announced visit for the purpose of conducting a Pre-Licensing inspection. LPA's met with Applicants (AP) Ryan Roche and Scott Messick, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly (RCFE). Application was submitted to Community Care Licensing on 12/08/2022. Facility is an existing facility and undergoing a Change of Ownership. There are 6 Residents in care under the current license. Facility is a one story, 6 bedroom, 2 bathroom home with an attached garage. A Fire Clearance was granted for 6 non-Ambulatory Residents on 01/19/2023. Facility is secured by a fence around the property. Adequate seating is available in the dining room as well as the living room. Two bedrooms are double occupancy and all are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms have wash basin and shower. Linen supply is ample supply for residents. Facility has a current food supply of two day perishables and seven day non-perishables. Smoke and carbon monoxide detectors are centrally wired and are operational. Fire extinguishers are mounted and charged. Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins were locked/stored in the laundry room. Hot water in bathroom was tested and is within regulatory requirements. First Aid kit observed contained all required items. Medication is stored in the locked hallway closet. The facility has activity supplies such as Bingo and trivia games. Facility has a covered patio with patio table and chairs. Side exit gate is unlocked and self latching. The Component III was waived because Applicants are Licensees for an existing facility.

The Pre-Licensing is complete and this facility has no deficiencies. All elements verified by LPA's appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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