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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005184
Report Date: 11/15/2021
Date Signed: 11/15/2021 11:30:45 AM

Document Has Been Signed on 11/15/2021 11:30 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:PREMIUM FAMILY CAREFACILITY NUMBER:
306005184
ADMINISTRATOR:IONESCU, EMANUELFACILITY TYPE:
740
ADDRESS:26732 AVENIDA SHONTOTELEPHONE:
(949) 452-0535
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Licensee Emanuel IonescuTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with Licensee Emanuel Ionescu and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden and with hospice waiver for three. . During this visit, there was no resident in care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA toured the interior and exterior portions of the facility. There were two shared and two 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 auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair. Hot water was measured at 110 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. 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 Licensee ; and copy of this report was left in the facility. Licensee agreed to inform Community Care Licensing Division if the facility will accept residents.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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