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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005254
Report Date: 10/03/2022
Date Signed: 10/03/2022 11:16:50 AM

Document Has Been Signed on 10/03/2022 11:16 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: 4DATE:
10/03/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emiliana Pinera, AdministratorTIME COMPLETED:
11:45 AM
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On 10/03/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the deficiency and immediate civil penalty citing during a case management visit conducted on 07/28/2022. LPA was greeted and granted entry into the facility by caregiving staff and explained the reason for the visit. Administrator Emiliana Pinera was notified of the visit by phone and arrived shortly afterwards to assist with the visit.

As of 10/03/2022, the deficiency cited under Health and Safety Code Section 1569.312 providing 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" has been cleared.

LPA requested and obtained the updated Physician Report and Individual Service Plan for resident R1 during the visit. Updated Physician Report is dated 08/01/2022 and the Individual Needs Assessment was done 07/31/2022 and confirmed that licensee has complied with the terms of the Plan of Corrections.

Staff members present at the time of the visit are noted to be adequately cleared and associated in Guardian. There are currently four (4) residents at the facility, three (3) of which are present during the visit and relaxing in their respective bedrooms.

LPA Saborit-Guasch conducted an exit interview with facility representative and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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