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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002429
Report Date: 08/16/2022
Date Signed: 08/19/2022 11:26:20 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/19/2022 11:26 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FAMILY CARE - PEPITA HOMEFACILITY NUMBER:
306002429
ADMINISTRATOR:RUSSELL VENANZIFACILITY TYPE:
740
ADDRESS:26741 PEPITA DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Russel Venanzi, Administrator
Edwin Abellana, caregiver
Cathy Berdan, caregiver		TIME COMPLETED:
04:00 PM
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An initial copy of this report had been generated under an incorrect facility number (306002428) and was amended to the right facility. On 08/16/2022 at 2:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA was greeted and granted entry by caregivers Edwin Abellana and Cathy Berdan after explaining the purpose of the visit.

At approximately 2:20pm, LPA accompanied by caregiver toured the physical plant of the facility. There are currently five (5) residents in care, three (3) of which are receiving hospice care. The residents are observed relaxing in the common area or in their respective bedrooms and appear clean and well taken care of. The four (4) bedrooms include all necessary components. An ample supply of linen is observed. The two (2) shared bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are stored in a kitchen cabinet secured by a magnetic lock, along with the centrally stored medication and resident files. LPA observed a sufficient supply of food and water present. Cleaning supplies are located in the locked attached garage as well as in a locked cabinet under the kitchen sink, secured by a key lock. LPA observed the facility has COVID-19 Precautions posters and all required department postings. The Administrator certificate for Russell Venanzi is expired and will need to be replaced with a current print-out showing current status as an administrator. The facility has an adequate supply of PPE. Several fire extinguishers are present and charged. Exits are equipped with functional sound alarms indicating an egress.

Caregiver Abellana is correctly cleared and fingerprinted in Guardian, however the staff association for Cathy Berdan has been terminated at the time of the visit in spite of being cleared. LPA provides guidance on the licensee's responsibility to maintain accurate and up-to-date staff association.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FAMILY CARE - PEPITA HOME
FACILITY NUMBER: 306002429
VISIT DATE: 08/16/2022
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CONTINUED FROM FORM LIC809

LPA and caregiver toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture is present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory regarding the Administrator certificate on display is issued along with one regarding staff association. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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