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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003492
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:16:53 AM

Document Has Been Signed on 07/12/2021 11:16 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:CASTILLA LANE VILLAFACILITY NUMBER:
306003492
ADMINISTRATOR:DIZON, EMMANUELFACILITY TYPE:
740
ADDRESS:24272 CASTILLA LANETELEPHONE:
(949) 716-8779
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Administrator Sherry Dizon TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced required annual inspection in this facility. LPA spoke with Administrator (AD) Sherry Dizon and stated the purpose of this visit.

The facility is licensed for capacity of six non-ambulatory and with hospice waiver for six. For this visit, there was one resident under hospice care.

About 10:04 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA observed three residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were six private resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and all auditory exit alarms were tested to be operational. Bathrooms were provided with grab bars; non-skid floor mats, and hot water was measured at 105 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion of the facility, patio furniture were observed in to be in good repair, and grounds were free of tripping hazards.

LPA reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Sherry Dizon and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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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