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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005385
Report Date:
12/07/2023
Date Signed:
12/07/2023 01:54:51 PM
Document Has Been Signed on
12/07/2023 01:54 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 II
FACILITY NUMBER:
306005385
ADMINISTRATOR:
RASSOULI ZADEHEI, FAHIMEH
FACILITY TYPE:
740
ADDRESS:
27561 ALMENDRA DRIVE
TELEPHONE:
(949) 322-1078
CITY:
MISSION VIEJO
STATE:
CA
ZIP CODE:
92691
CAPACITY:
6
CENSUS:
5
DATE:
12/07/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:10 PM
MET WITH:
Faith Rasouli - Licensee
TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding the status of the physical plant.
While investigating complaint control # 22-AS-20201228104338 an unannounced visit was made and during the tour of the facility LPA Haley noticed some areas in the kitchen that needed cleaning and some areas that needed repair.
Dusty was observed in the kitchen on the cabinets above the stove.
Dust was observed on top of the refrigerator and covered the items sitting there.
Microwave was in disrepair. The door would not close properly
Cabinet on the right side of the stove missing the cabinet door.
During the visit Licensee Rasouli called repairmen who arrived during the visit and cleaned the dusty areas of the kitchen and made repairs to the cabinets.
Licensee Rasouli already ordered a new microwave to replace the broken one in the kitchen.
Licensee Rasouli was advised on the importance of keeping the facility clean and in good repair at all times.
No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Jerome Haley
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/07/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/07/2023
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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