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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002429
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:52:06 AM

Document Has Been Signed on 06/02/2022 10:52 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: 6DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Paul Bartolome, caregiver
Russel Venanzi, administrator		TIME COMPLETED:
11:15 AM
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On 06/02/2022 at 10:30am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced case management visit to the facility. LPA arrived at facility, was greeted and granted entry by Paul Bartolome, caregiver after explaining the purpose of the visit and undergoing the facility's COVID-19 screening and sign-in procedure. LPA observed a check-in station in proximity to the facility entry point used for visitors. Administrator Russel Venanzi was called and arrived shortly afterwards to assist with the visit.

LPA verified the staff present and their association status in Guardian. Staff present are background checked but their facility association is for another of the facilities managed by the licensee/administrator under license number 306002428. LPA consults with licensee to remind them of their responsibility to ensure staff are not only background checked but also associated to all facilities to which they may be assigned to work.

LPA along with licensee also verified the centrally stored medication is no longer being pre-poured.

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 is however being issued in regard to adequate staff association to the facility. This report was reviewed with facility representative and a copy of this report and appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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