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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006388
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:17:40 PM


Document Has Been Signed on 01/11/2024 02:17 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GRANNY'S PLACE #1FACILITY NUMBER:
306006388
ADMINISTRATOR:MALACA, ROCHELFACILITY TYPE:
740
ADDRESS:24132 DELPHI STREETTELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
01/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Compliance Manager - Michelle NesbittTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection for a change of ownership. LPA arrived at the facility and was greeted and granted entry by Compliance Manager (CM) Michelle Nesbitt. An application to operate a Residential Care Facility (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 7/18/2023.

Structure: The facility is a one-story home with six client resident bedrooms, seven bathrooms, living room, kitchen, dining room, caregiver room, backyard and attached two car garage. There are two exit gates in the back yard. The backyard has 3 shaded seating areas.

Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 114.4 degrees Fahrenheit, 113.2 degrees Fahrenheit,110.7 degrees Fahrenheit, 111 degrees Fahrenheit and 109.6 degrees Fahrenheit.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored under the kitchen sink.

Medications, First-Aid Kit & Files: Medication is stored in a locked closet near the dining room. The First Aid Kit is stored in a locked cabinet in the kitchen. Records are digitized and were accessible to LPA during inspection.

Fire Extinguisher: LPA observed the fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. Extinguishers were serviced on 10/4/2023.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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