306006320-9-18-2024-22-AS-JHAY-D99357-20240918175615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006320
Report Date: 09/18/2024
Date Signed: 09/18/2024 05:56:36 PM

Document Has Been Signed on 09/18/2024 05:56 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:	MIRADA MANOR/GREENLEAF		FACILITY NUMBER:	306006320
ADMINISTRATOR/ DIRECTOR:	BROWN, PRECIOUS		FACILITY TYPE:	735
ADDRESS:	8616 GREENLEAF AVENUE		TELEPHONE:	(818) 274-1809
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 3	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	Olatomiwa Obawole		TIME VISIT/ INSPECTION COMPLETED:	06:10 PM

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Licensing Program Analysts (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Oyewole Jose who spoke with LPA Haley via telephone and provided a current liability insurance policy via email.

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

Client bathrooms were in compliance with regulation guidelines. Hot water temperatures was measured 103.8 degrees Fahrenheit before the water was turned off due to a slow draining sink. No hazardous items were observed in the client bathrooms, and all grab bars were tightly secured to the wall. Hygiene items are locked in a bathroom cabinet.

A large supply of linens are kept in a hallway closet. Below the linens in a locked cabinet space are two first aid kits with all the necessary requirements. Gallons of water were observed and additional first aid supplies were observed.

In the kitchen knives and sharp objects are kept locked in a cabinet below the counter. Hazardous cleaning materials are kept locked under the sink. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets.

The garage was organized, and walkways were free of obstruction. Three additional refrigerators were observed in the garage with an additional supply of food items in all three refrigerators.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MIRADA MANOR/GREENLEAF	FACILITY NUMBER: 306006320
	VISIT DATE: 09/18/2024

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Incontinent care supplies were observed. An emergency bin of emergency supplies is kept in the garage. A folding table and a sunshade for the backyard was observed.

There's a office area where staff and client files are stored in locked filing cabinets. Client medications and client P&I funds are also stored in a locked filing cabinet in the office area. Old paperwork, and exercise bike and other facility items are stored in the office area.

The backyard was clean, organized, and walkways were free of obstruction. Chairs were observed and the portable/movable sunshade was observed in the garage.

Smoke detectors, and the carbon monoxide detector tested operational. A fully charged fire extinguisher was observed mounted on the wall in the kitchen.

An emergency evacuation drill was conducted September 11, 2024 and will continue to be conducted quarterly for staff on each shift.

During the visit 3 staff files were reviewed, 3 client files were reviewed, 3 client P&I funds were reviewed, and 3 client medications were reviewed.

No deficiencies are being cited as a result of today’s visit. Technical Advisories will be issued.

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

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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