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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005254
Report Date: 06/03/2024
Date Signed: 06/03/2024 01:49:50 PM

Document Has Been Signed on 06/03/2024 01:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EMY'S PLACE OF MISSION VIEJOFACILITY NUMBER:
306005254
ADMINISTRATOR/
DIRECTOR:		PINERA, DOMINADOR C JRFACILITY TYPE:
740
ADDRESS:24176 CARRILLO DRIVETELEPHONE:
(949) 273-5987
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
06/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Emiliana Pinera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility administrator Emiliana Pinera.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home. Facility has four private rooms and one staff room, as well as two shared bathrooms and one half bathroom in addition to the common living areas. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently four residents admitted to the facility with one currently at the hospital. Two residents are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed four resident files and two staff files.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Four Technical Assistance Advisory Note were provided to the licensee based on consultation provided during the visit. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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 06/03/2024 01:49 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 06/03/2024 at 01:29 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: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Per California Code of Regulations Section 87305 Alterations to Existing Building or New Facilities: "(a) Prior to construction or alterations, all facilities shall obtain a building permit."

This requirement is not met as evidenced by: During the facility walkthrough, it was observed that the main living area had been partitioned to create a room to be used by overnight staff. The room is not reflected on the sketches on file and permits were not sollicited.
Deficient Practice Statement
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Based on observation and review of the facility sketch, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee will retroactively request permission to add the partition to the physical plant and confirm the compatibility of the alteration with the facility's fire clearance. Documentation to be provided to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024


LIC809 (FAS) - (06/04)
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