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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003822
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:12:38 PM

Document Has Been Signed on 12/06/2022 03:12 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADRIANA ELDERLY CARE HOME IIIFACILITY NUMBER:
306003822
ADMINISTRATOR:MENDOZA, RICHARDFACILITY TYPE:
740
ADDRESS:25492 CLASSIC DRIVETELEPHONE:
(949) 916-3828
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Kevin MendozaTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Kevin Mendoza arrived and was also present for the visit.

Administrator Adriana Mendoza has a current Administrators Certificate that expires 04/06/23. There were four residents present during the visit.

At 02:35 PM LPA Haley and staff began the inspection at the entrance of the facility. A screening station with hand sanitizer, face mask and screening logs was observed at the front door. Next to the screening station LPA observed a locked medication closet with a first aid kit with all the required elements inside the locked medication closet. Resident files are also stored in the locked medication closet. Knives and sharp objects are locked in the medication cabinet as well.

Resident bedrooms were clean, organized, and had all necessary requirements. Resident bathrooms were clean, organized, and grab bars were present in the showers and near the toilet in each resident bathroom. In bathroom #1 hot water was measured at 113.9 degrees Fahrenheit and 114.8 degrees Fahrenheit in bathroom #2. Clean linen was observed in a hallway cabinet outside the resident rooms.

The living room area was clean and neatly organized. LPA Haley observed residents watching the television in the living room.

The kitchen area was clean and organized. All burners on the stove were operational. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items. A fully charged fire extinguisher was mounted on the wall near the dining room table.


Continued on LIC809C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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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: ADRIANA ELDERLY CARE HOME III
FACILITY NUMBER: 306003822
VISIT DATE: 12/06/2022
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The backyard had clear walkways, free of tripping hazards. The side exit gate was self closing and self latching. LPA Haley observed a pool surrounded by a gate that meets regulation requirements. Tables and chairs was observed under a patio like covering in the backyard.

The garage was used to store miscellaneous facility items. LPA Haley observed a washer and dryer in the garage. Next to the washer and dryer LPA observed a locked tool box with detergents, soaps, and bleach. There's a locked closet in the garage next to the washer and dryer used to store additional cleaning items. LPA observed several miscellaneous facility items being stored: wheelchairs, walker, commodes, dressers, chairs, mattress, pillows, clothing, bedframes, and several boxes of adult diapers.

LPA Haley advised AD Mendoza on the importance of making sure the facility has enough perishable and non perishable food items in the facility at all times.

All smoke detectors were tested and are operational.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report and LIC9102 was provided to Administrator Mendoza.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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