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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005570
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:58:25 PM

Document Has Been Signed on 06/07/2022 12:58 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:SAN GIOVANNI BOSCO RESIDENTIAL CAREFACILITY NUMBER:
306005570
ADMINISTRATOR:JOHN PIRAINOFACILITY TYPE:
740
ADDRESS:24596 DARDANIA AVETELEPHONE:
(949) 583-9143
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:John Piraino, Dina PirainoTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection in this facility focusing primarily on the Infection Control. LPA was greeted and granted entry by Caregiver James Cruz after completing the Coronavirus 2019 (COVID-19) screening procedure. LPA observed the screening station and the required COVID-19 postings by the front entrance. The PUB475 See Something, Say Something was posted in the hallway in the size of 8.5"x11." The Administrator's Certificate for John C. Piraino expires on 10/03/2022. Administrator (Admin) John Piraino arrived shortly and assisted with the tour around 11:40 am.

At 10:52 am, LPA toured the interior and exterior portions of the facility with Caregiver Cruz. The facility is a single level structure and licensed for six non-ambulatory of which one may be bedridden; and has a hospice waiver for four residents. As of today, the facility had two residents of which none are in hospice care. Upon entry, LPA observed the residents in their respective bedrooms resting. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms tested operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hand washing signs were not observed in Restrooms #1 and #2 but the signage was posted in Restroom #3 where the residents mainly use. Hot water measured below 105 degrees Fahrenheit in all three restrooms: 92.8 degrees Fahrenheit in Restroom #1, 93.9 degrees Fahrenheit in Restroom #2, and 102.3 degrees Fahrenheit in Restroom #3. Admin adjusted the water temperature during the visit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications and sharp items were inaccessible to the residents in care. Cleaning solutions and laundry detergents were accessible to the residents in care, but the items were removed during the visit. LPA observed the knives were locked away in the medication closet due to the drawer not locking. LPA requested the locking mechanism for the knife drawer to be repaired. Fire extinguisher was mounted and charged in the kitchen.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAN GIOVANNI BOSCO RESIDENTIAL CARE
FACILITY NUMBER: 306005570
VISIT DATE: 06/07/2022
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For the exterior portion, the facility had patio furniture under an umbrella, and grounds were free of tripping hazards. The side gate was self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPE supplies stored in the closet.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Residents are allowed to use the staff mobile phone upon request.

LPA Cho reviewed the approved COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator John Piraino, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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