<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005254
Report Date: 04/25/2022
Date Signed: 04/25/2022 10:47:00 AM

Document Has Been Signed on 04/25/2022 10:47 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:EMY'S PLACE OF MISSION VIEJOFACILITY NUMBER:
306005254
ADMINISTRATOR:PINERA, DOMINADOR C JRFACILITY TYPE:
740
ADDRESS:24176 CARRILLO DRIVETELEPHONE:
(949) 273-5987
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dominador Pinera Jr
Emiliana Pinera, Administrator		TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Dominador Pinera after explaining the purpose of the visit and being screened for COVID-19. Administrator Emiliana Pinera arrived later to assist with the visit.

At approximately 10:00am, LPA accompanied by Dominador Pinera toured the inside and outside of the facility. There are currently three (3) residents in care, none of which are on hospice. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. The bedrooms include all necessary components. A physician's order for half rails is observed to be present for one (1) resident. Bathrooms are equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected. Staff present is observed to be correctly associated in Guardian.

Sharp instruments are kept in a cabinet secured by a magnetic lock. Cleaning supplies and toxic substances are securely stored in the attached garage as well in a locked cabinet. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted to LPA Joseph Alejandre. LPA has informed administrator that a new Infection Control document has been released and will have to be submitted to Community Care Licensing by 06/30/2022.

CONTINUED IN FORM LIC809C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: EMY'S PLACE OF MISSION VIEJO
FACILITY NUMBER: 306005254
VISIT DATE: 04/25/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. The exterior of the facility is free of debris and obstruction, with a shaded area where outdoor furniture is located for the residents' and visitors' enjoyment. The perimeter gate marked as an exit route is self-latching and can easily be opened in an evacuation. No bodies of water are observed on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3