306006393-1-11-2024-22-AS-DLMN-CZDU2L-20240111141208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006393
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:12:15 PM

Document Has Been Signed on 01/11/2024 02:12 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 #4		FACILITY NUMBER:	306006393
ADMINISTRATOR:	MALACA, ROCHEL		FACILITY TYPE:	740
ADDRESS:	25665 SABINA AVENUE		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	01/11/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Compliance Manager - Michelle Nesbitt		TIME COMPLETED:	12:00 PM

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) 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 a shaded 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 115.3 degrees Fahrenheit, 116.2 degrees Fahrenheit,115.1 degrees Fahrenheit, 109.8 degrees Fahrenheit and 107.4 and 114.3 degrees Fahrenheit. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents 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 a locked closet near the entryway. 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 Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
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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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 #4	FACILITY NUMBER: 306006393
	VISIT DATE: 01/11/2024

NARRATIVE

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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. Facility also has a box of activity supplies on site.

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 Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
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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