306006297-2-27-2024-22-AS-JHAY-D2URMJ-20240227120849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006297
Report Date: 02/27/2024
Date Signed: 02/27/2024 12:09:12 PM

Document Has Been Signed on 02/27/2024 12:09 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:	DEL'S HAVEN IV		FACILITY NUMBER:	306006297
ADMINISTRATOR:	MANALO, DIANNA		FACILITY TYPE:	740
ADDRESS:	23822 STILLWATER LANE		TELEPHONE:	(949) 258-2063
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 5	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Dianna Manalo - Administrator		TIME COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Administrator (AD) Dianna Manalo’s Administrator certificate requirements have been completed and were submitted November 16, 2023 and is pending approval.

Del’s Haven IV is a one-story community with five bedrooms and two bathrooms. The facility capacity is 6 and the census was 5 during today’s visit. Residents were observed in the backyard getting some sunlight while exercising, and one resident was in their bedroom during the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines.

In the resident bathrooms, the hot water temperatures were measured. In bathroom #1 hot water measured at 115.1 degrees Fahrenheit, and in bathroom #2 hot water measured at 111.7 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms. Both showers had nonskid matts and the grab bars were secure.

In the hallway, there was a cabinet with clean linens next to bathroom #1. Next to the closet with clean linens was a fully charged fire extinguisher mounted on the wall. There was a second cabinet with extra blankets and a vacuum. There was also a carbon monoxide detector mounted on the wall in the hallway.

In the kitchen LPA Haley observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in the drawer next to the stove. Medications were locked in a cabinet next to the refrigerator. Below the locked medication cabinet, there’s a cabinet with resident and staff files.

Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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: DEL'S HAVEN IV	FACILITY NUMBER: 306006297
	VISIT DATE: 02/27/2024

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Hazardous cleaning items are kept locked under the sink. A first aid kit with all the required elements is locked in a cabinet below the kitchen counter. The stove was clean and all five burners were operational.

In the garage, there is a supply of facility items being stored in the center of the garage. Walkways were clear and free of obstruction. A backup supply of food items was observed in the refrigerator and deep freezer. There is an emergency supply of COVID PPE items: N95 mask, gowns, and hand sanitizers. All the residents have an emergency bag ready to go, and the facility has a emergency kit prepared and ready to go. In the emergency kit is an emergency food supply, flashlights, batteries, toilet paper and other items. LPA Haley observed an emergency supply of water as well.

The backyard was clean and organized. The walkways were clear and free of obstruction. A shaded patio area with tables and chairs was observed. Both exit doors were self-closing and self-latching.

Smoke detectors were observed in all resident rooms, the hallways, living room and in the dining room area. During the inspection smoke detectors were tested and were operational. A second fully charged fire extinguisher was observed mounted on the wall in the dining room.

An emergency evacuation drill was conducted in February 2024 and will continue to be conducted quarterly for staff on each shift.

No deficiencies were observed during today’s visit.

An exit interview conducted, and a copy of this report was provided to Administrator Manalo.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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