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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005254
Report Date: 07/28/2022
Date Signed: 07/28/2022 03:15:48 PM

Document Has Been Signed on 07/28/2022 03:15 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: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:
07/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Emiliana Pinera, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to conduct a case management following up on an incident reported to Community Care Licensing. LPA identified himself and was granted entry by Emiliana Pinera, Administrator and explained the purpose of the visit.

On 07/01/2022, R1 was able to exit the facility on their wheelchair unsupervised and was later found on the street in proximity to the facility and brought back by the Mission Viejo Police Department.

During visit LPA requested to consult R1's resident file (as documented in the attached form LIC858). The Medical Assessment conducted on 06/15/2021 by the resident's primary care provider indicates that the resident is unable to leave the facility unassisted and requires supervision. Given the assessment, the lack of supervision by the facility is corroborated.

Based on the file review conducted today, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and an immediate civil penalty is being assessed. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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Document Has Been Signed on 07/28/2022 03:15 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/28/2022 at 02:53 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: EMY'S PLACE OF MISSION VIEJO
FACILITY NUMBER: 306005254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited
HSC
1569.312

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Health and Safety Code section 1569.312 provides that every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety.
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Licensee will obtain an updated Physician Report and update the resident's Individual Service Plan accordingly.

Additionally, licensee will hire additional staff to provide supervision at all times as required.
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Based on the file review conducted, this requirement is not being met as evidenced by the fact that resident R1 was able to leave the facility unattended in spite of a physician report requiring supervision to leave the facility.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022


LIC809 (FAS) - (06/04)
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