306006588-10-23-2024-22-AS-JALE-DABRNY-20241023131106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006588
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:11:34 PM

Document Has Been Signed on 10/23/2024 01:11 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	LAGUNA SHORES MENTAL HEALTH		FACILITY NUMBER:	306006588
ADMINISTRATOR/ DIRECTOR:	SORENSON, KATHERINE		FACILITY TYPE:	772
ADDRESS:	28812 ALOMA AVENUE		TELEPHONE:	(949) 226-5146
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 6		CENSUS: 0	DATE:	10/23/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Katherine Sorenson		TIME VISIT/ INSPECTION COMPLETED:	01:25 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 Analysts (LPAs) Joseph Alejandre, Nancy Guillen and Brandon Lopez conducted an announced visit to the facility to conduct the pre-licensing inspection. LPAs met with Applicant Katherine Sorenson, Lead Therapist Matthew Darst, Jordan Ebach, and Damian Raburn were present. An initial application to operate a Social Rehabilitation Facility (SRF) was submitted to CCL on April 23, 2024. The facility is to have a capacity of 6 ambulatory clients. LPAs observed the following. This is a new facility and there are no clients. The facility phone number is 949-503-1237. Structure: The facility is a multi-level house with 2, 2 car garages on the ground level. The house has 4 bedrooms, 5 bathrooms, living room, dining room, family/group room, kitchen, counseling office and staff office. Air/Heating: Central air/heating system installed with a central panel to control entire house. Client Bedrooms: There are 4 client Bedrooms, 2 are shared and 2 are private. The bedrooms are spacious and will easily accommodate the clients' belongings. All client rooms had the required furnishings and linens. Medications, First-Aid Kit & Book: The first aid kit and the first aid manual are stored in the counseling office. The first aid kit has all the required elements. Medications will be stored in the counseling office and kept in a locked safe.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAGUNA SHORES MENTAL HEALTH	FACILITY NUMBER: 306006588
	VISIT DATE: 10/23/2024

NARRATIVE

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Bathrooms:
All 5 bathrooms have working showers and toilets. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review. The emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

Food Service:
There is a 7 day supply of non-perishable food and a 3 day supply of emergency food.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. All 3 Fire Extinguishers are fully charged and mounted on the wall.

Appliances:
There is a 5 burner gas stove-top which lights unassisted, an oven, microwave oven, two refrigerators and two dishwashers in the kitchen. The washer and dryer are in the laundry room on the second floor. The laundry is kept locked. All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked in walk in kitchen pantry.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured at 105.9 to 120.0 degrees Fahrenheit.

Client & Staff Files:
The Client and Staff Records will be kept locked in the counseling office.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAGUNA SHORES MENTAL HEALTH	FACILITY NUMBER: 306006588
	VISIT DATE: 10/23/2024

NARRATIVE

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Reading Material, Games, Equipment & Materials:
Games and puzzles are stored in the living room. There is a ping pong table in the family/group room.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Ryan Ferdig on August 8, 2024.

Component III:
Component three completed with applicant.

Facility is ready to be licensed.

Applicant was informed today that the final approval will be processed by CAB (Cental Application Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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