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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002428
Report Date: 09/21/2021
Date Signed: 09/22/2021 10:55:46 AM

Document Has Been Signed on 09/22/2021 10:55 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 - EL MAR HOMEFACILITY NUMBER:
306002428
ADMINISTRATOR:VENANZI, RUSSELLFACILITY TYPE:
740
ADDRESS:26542 EL MAR DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Russell VenanziTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Bryla Tesnado and Donna Santos . Administrator Russell Venanzi was contacted and arrived approximately a half hour after LPA. The focus of the visit was Infection Control. During the visit LPA toured the facility with Bryla Tesnado and the following was observed:

Covid signage was posted at the front entrance of facility with a sanitization station. LPA's temperature was not taken upon arrival and a sign in sheet was not made available. Facility has required Department postings. Administrator Certificate for Russell Venanzi expired on 9/5/21. Mr. Venanzi stated that he has renewed his Certificate and is waiting on Sacramento. LPA toured all resident rooms. Rooms were clean and sanitary. All restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed watching tv and napping . Licensee has required Mitigation plan and Emergency Disaster Plan. LPA observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with Administrator and staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review Department PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions Entertainment. PIN 21-32 -ASC provides Masking Guidelines. An exit interview was conducted a copy of this report and PIN 21-32-ASC was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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