306006362-10-23-2023-22-AS-CGUZ-CWVN7H-20231023101245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006362
Report Date: 10/23/2023
Date Signed: 10/23/2023 10:12:56 AM

Document Has Been Signed on 10/23/2023 10:12 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:	ALTER MENTAL HEALTH - DANA POINT, LLC		FACILITY NUMBER:	306006362
ADMINISTRATOR:	BUSS, WHITNEY		FACILITY TYPE:	772
ADDRESS:	33522 AVENIDA CALITA		TELEPHONE:	(949) 538-7457
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 6		CENSUS: 0	DATE:	10/23/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Whitney Buss		TIME COMPLETED:	10:30 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) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Whitney Buss and Operations Manager (OM) Will Lemmy. An application to operate a Social Rehabilitation Facility (SRF) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden clients was received by CCL on 5/22/2023. Structure: The facility is a two-story house with four client bedrooms, three bathrooms, two living areas, kitchen, dining area, laundry room, staff office and attached four-car garage. LPA observed the See Something, Say Something poster (PUB 475) prominently posted. There is a backyard with an exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is mounted in the hallway and has all the required elements.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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: ALTER MENTAL HEALTH - DANA POINT, LLC	FACILITY NUMBER: 306006362
	VISIT DATE: 10/23/2023

NARRATIVE

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

Pool/Jacuzzi:
There is a pool in the backyard. Pool was observed to be fenced and inaccessible.

Fire Extinguisher:
Fire extinguishers were observed to be mounted and fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, art supplies and other recreational materials for the client’s use that will be kept in the living room.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 07/18/2023. No special conditions noted.

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

Bedrooms Staff:

There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 105.0 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC809 (FAS) - (06/04)

Page: 2 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: ALTER MENTAL HEALTH - DANA POINT, LLC	FACILITY NUMBER: 306006362
	VISIT DATE: 10/23/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

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:
Gas stove, oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An 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: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC809 (FAS) - (06/04)

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