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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003858
Report Date: 09/23/2021
Date Signed: 09/23/2021 01:30:46 PM

Document Has Been Signed on 09/23/2021 01:30 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:ST. FRANCIS' HOME CAREFACILITY NUMBER:
306003858
ADMINISTRATOR:RAYMOND MENDOZAFACILITY TYPE:
740
ADDRESS:23822 VIA NAVARRATELEPHONE:
(949) 916-9957
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
09/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Raymond Mendoza TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Norman Woodridge conducted an unannounced visit to the facility to conduct a case management visit and to review Coronavirus 2019 (COVID-19) mitigation plan. LPA stated the purpose of the visit, was granted entry by administrator, Raymond Mendoza, and went through screening procedure upon entering the building.

LPA conducted a tour of the inside and outside of the facility. LPA spoke with administrator, Raymond Mendoza, and discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPA discussed Covid-19 Mitigation Plan with administrator and assisted administrator with making revisions to the mitigation plan.

The facility was cited for the following Type A deficiency: LPA observed toxins including rubbing alcohol that were not was not made inaccessible to the residents. The administrator immediately corrected the deficiencies.

LPA Norman Woodridge conducted an exit interview with administrator and provided him with a copies of this report and PIN 21-38-ASC.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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Document Has Been Signed on 09/23/2021 01:30 PM - It Cannot Be Edited


Created By: Norman Woodridge On 09/23/2021 at 01:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. FRANCIS' HOME CARE
FACILITY NUMBER: 306003858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia....cleaning supplies and disinfectants.

This requirement not met as evidenced
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The administrator immediately corrected the deficiency by replacing the lock on the garage door and locking the door. Rubbing alcohol was stored away.Training will be provided to staff to ensure items are made and kept inassessable.
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During the visit, LPA observed cleaning agents and toxins, which was accessable and posed a health and safety risk to residents with demetia.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Marina Stanic
LICENSING EVALUATOR NAME:Norman Woodridge
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
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