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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006389
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:10:56 PM


Document Has Been Signed on 01/11/2024 02:10 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 #2FACILITY NUMBER:
306006389
ADMINISTRATOR:MALACA, ROCHELFACILITY TYPE:
740
ADDRESS:25642 AURORA WAYTELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
01/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Compliance Manager - Michelle NesbittTIME COMPLETED:
11:00 AM
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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. LPA discussed with CM that, while at Granny's Place #2, they would be reviewing documentation for Granny's Place #1, #3 and #4 to make the best use of time. 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 five client resident bedrooms, three bathrooms, living room, kitchen, dining room, sun room, staff room, laundry room, backyard and attached two car garage. There is one exit gates in the back yard. The backyard has a seating area.

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 117.5 degrees Fahrenheit, 116.9 degrees Fahrenheit and 116.5 degrees Fahrenheit in resident bathrooms.

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

Medications, First-Aid Kit & Files: Medication and first aid kit will be stored in locked cabinets in the laundry area. There is also a first aid kit hanging on the wall in the kitchen. Records are digitized and were accessible to LPA during inspection.
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)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 #2
FACILITY NUMBER: 306006389
VISIT DATE: 01/11/2024
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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

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/15/2023.

Component III: Information provided about how to operate the facility within compliance and reporting requirements.

Activity Materials: The facility has a facility calendar with various outings for residents. Facility also has exercise equipment, music and other electronics, plenty of space to lounge and relax and more.

Linens: A supply of extra linen is stored in the hallway closet.

Emergency Phone Numbers, Exit Plan and Menu: Posted and available for review.

Food Service: There is 2-day supply of perishable food and a 7-day supply of non-perishable food on hand.

Smoke Detectors: Smoke detectors and carbon monoxide detectors were tested and observed to be 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. Exit interview was conducted and a copy of this report was provided to designated AD
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
LIC809 (FAS) - (06/04)
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