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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005160
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:17:33 AM

Document Has Been Signed on 05/10/2022 11:17 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:PACIFIC SHORES OF MISSION VIEJOFACILITY NUMBER:
306005160
ADMINISTRATOR:ZUEHL HERMINIA AMYFACILITY TYPE:
740
ADDRESS:24741 ACROPOLIS DRIVETELEPHONE:
(949) 683-8736
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jonathan LizardoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced required annual (mitigation) inspection in this facility. LPA was greeted and granted entry by Caregiver Zenaida De Leon and completed the Coronavirus 2019 (COVID-19) screening procedure. LPA stated the purpose of the visit and toured the facility with Administrator/Caregiver Montero Benigno Bulanadi. Administrator (Admin) Herminia (Amy) Zuehl joined shortly around 9:45 am.

The facility is a single level structure and licensed for six non-ambulatory residents of which one may be bedridden and has a hospice waiver for four residents. There is one resident in hospice care. For this visit, there are five residents in care and three staff members on duty. LPA toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms tested operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 112.1 degrees Fahrenheit in Bathroom #1 and 111.5 degrees Fahrenheit in the caregiver's bathroom (Bathroom #2). Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Sharp items were inaccessible to the residents in care. LPA observed medications and cleaning supplies were accessible to the residents as the laundry cabinet and the medication room were unlocked. Both laundry cabinet and medication room were locked during the visit. LPA observed 4 prescription medications in Bedroom #3 which were removed and locked away during the visit. The fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture under a patio lattice, and the grounds were free of tripping hazards. Side exit doors were self-latching and self-closing. LPA reviewed the approved COVID-19 Mitigation Plan.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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: PACIFIC SHORES OF MISSION VIEJO
FACILITY NUMBER: 306005160
VISIT DATE: 05/10/2022
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LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.


For this visit, there are no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Herminia (Amy) Zuehl and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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