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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005385
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:16:43 PM

Document Has Been Signed on 02/06/2025 04:16 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:ORANGE COUNTY CARE HOME IIFACILITY NUMBER:
306005385
ADMINISTRATOR/
DIRECTOR:		RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:27561 ALMENDRA DRIVETELEPHONE:
(949) 322-1078
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Faith Rassouli, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:29 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Fatimeh Rassouli was notified of the visit via telephone and arrived shortly afterwards to assist with the visit.

There are currently six residents in care, none of which are currently receiving hospice care. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage accessed through the side yard. The facility has six private bedroom and two shared bathrooms in addition to one staff room which is kept inaccessible from residents in care.

Bedrooms appeared clean and sanitary. Physician orders for all postural supports in use reviewed and verified to be on file. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars. Shower chairs are in use but no slip mats are present. Consultation provided. Hot water temperature measured at 118F in a bathroom with a faucet used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Cleaning supplies are stored in the locked garage and in a secure cabinet under the kitchen sink. Fire extinguisher is charged and mounted. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure closet located in the administrative office. The attached garage is inaccessible to residents and is used for storage and laundry, with an additional refrigerator/freezer present.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
VISIT DATE: 02/06/2025
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. The perimeter gates on both sides of the property are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all admitted residents with no discrepancies observed. Three resident interviews conducted during the visit. There are three residents with physician orders for diabetes-related injections. The physician reports for two of those residents confirm the residents are able to self-administer with assistance. The third resident appears alert and oriented however the physician did not confirm the ability to self-administer safely. Licensee will reach out to the resident's primary care physician to get the assessment documented. Consultation provided.

There are no bedridden residents present on the premises. LPA reviewed four staff records which were found to be complete. Annual training as well as CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and three consultations are provided. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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