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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004628
Report Date: 01/06/2022
Date Signed: 01/06/2022 12:27:24 PM

Document Has Been Signed on 01/06/2022 12:27 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:CASA DOCTORA IIIFACILITY NUMBER:
306004628
ADMINISTRATOR:KRAMER, PAUL/ESTELAFACILITY TYPE:
740
ADDRESS:25492 MAXIMUS STREETTELEPHONE:
(949) 380-7379
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
01/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Estela KramerTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection. Administrator (AD) Estela Kramer arrived in the facility shortly after being notified about the presence of LPA in the facility. LPA met with AD and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which two may be bedridden; and with hospice waiver for six. There was no resident under hospice care.

About 11:35 AM , LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were five residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were four private and one shared resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid-floor mats. Hot water was measured at 115 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, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self-latching and self closing. LPA Marin 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 Estela Kramer and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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