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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006390
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:21:06 PM


Document Has Been Signed on 01/11/2024 02:21 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 #3FACILITY NUMBER:
306006390
ADMINISTRATOR:MALACA, ROCHELFACILITY TYPE:
740
ADDRESS:24695 DORIA AVENUETELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
01/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Compliance Manager - Michelle NesbittTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting an initial pre-licensing inspection. 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 four client resident bedrooms, two bathrooms, living room, kitchen, dining room, staff room, laundry room, backyard with pool and attached two car garage. There is one exit gate in the back yard. The backyard has a shaded seating area. The pool is surrounded by a fence that both latches and locks.

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 112.3 degrees Fahrenheit and 116 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 files will be stored in a locked closet near the front of the house. First aid kit will be in 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.
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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