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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005385
Report Date: 02/28/2022
Date Signed: 02/28/2022 03:54:11 PM

Document Has Been Signed on 02/28/2022 03:54 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:ORANGE COUNTY CARE HOME IIFACILITY NUMBER:
306005385
ADMINISTRATOR:RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:27561 ALMENDRA DRIVETELEPHONE:
(949) 322-1078
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Faith Rasouli, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility, explained the purpose of the visit and was greeted by the caregiving staff and granted entry. Administrator Faith Rasouli arrived shortly after being called by the caregiving staff present.

At approximately 3:00pm, LPA accompanied by Administrator began the tour of the facility. There are currently five (5) residents in care, including two (2) on hospice and one (1) currently at a Skilled Nursing Home after sustaining a fall. The residents are observed relaxing in their bedrooms and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station right at the entrance of the facility where visitors temperature checks are being documented. LPA observed the facility has COVID-19 Precautions posters, all required department postings. Some hand washing signs are posted however some have gone missing in two bathrooms and will need to be replaced promptly. LPA observed a sufficient supply of food and water. Facility has an adequate supply of PPE stored in the attached garage. LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris and well-maintained with self-latching gates that can easily be opened on both sides of the house. All 6 individual bedrooms were observed to have all required components. Bathrooms are equipped with grab bars and slip mats.
The facility has completed and submitted their LIC808 Mitigation Plan which has been approved by LPA Norman Woodridge on 07/26/2021.

Based on the observations made during today’s visit, deficiencies are being cited today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report and appeals rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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 02/28/2022 03:54 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 02/28/2022 at 03:37 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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Type A 02/28/2022 CCR 87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons ther than employees responsible for the supervision of the medication. This requirement is not met as evidenced by: LPAs observed 24hr supply of prepared medication being stored in an unlocked drawer.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator will provide LPA with proof of the deficient lock being replaced.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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