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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006298
Report Date: 05/31/2023
Date Signed: 05/31/2023 11:08:34 AM

Document Has Been Signed on 05/31/2023 11:08 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:SENIOR SOCIAL CLUB OF MISSION VIEJOFACILITY NUMBER:
306006298
ADMINISTRATOR:HANSEN, MARKFACILITY TYPE:
775
ADDRESS:24041 MARGUERITE PKWYTELEPHONE:
(858) 722-9583
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 60CENSUS: 0DATE:
05/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark HansenTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Mark Hansen and Consultant Westan Harmer. An application to operate an Adult Day Program (ADP) for (60) capacity, (60) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 1/17/2023.

Structure:
The facility is a one-story commercial building with one main room, two bathrooms, two staff offices, an activity room, a kitchen, a storage room, an electrical room, and a private leisure room. LPA observed the See Something, Say Something poster (PUB 475) in the entrance way of the facility. There is no backyard or outdoor area.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in one of two staff offices.

Medications, First-Aid Kit & Book:
Medication will be stored in a cabinet located in a locked staff office. First aid kits are located throughout the facility including one that will be centrally stored with medication. First aid kits have all the required elements.

Resident & Staff Files:
Records will be kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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 3
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: SENIOR SOCIAL CLUB OF MISSION VIEJO
FACILITY NUMBER: 306006298
VISIT DATE: 05/31/2023
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Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility will provide the daily newspaper. Various games, such as Connect 4, card and board games are kept in the activity room, along with multiple toys and arts and crafts material.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 03/14/2023. Special conditions noted “All 60 ambulatory will be able to freely come and go.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bathrooms:


All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 108.3 degrees Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

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

Appliances:
All appliances were inspected and are operational.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
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: SENIOR SOCIAL CLUB OF MISSION VIEJO
FACILITY NUMBER: 306006298
VISIT DATE: 05/31/2023
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The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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