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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005762
Report Date: 05/20/2021
Date Signed: 05/20/2021 10:48:00 AM

Document Has Been Signed on 05/20/2021 10:48 AM - 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:RELIANCE SENIOR HOMEFACILITY NUMBER:
306005762
ADMINISTRATOR:SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24672 ELOISA DRTELEPHONE:
(949) 295-6854
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
05/20/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced post licensing inspection to this facility. LPA met with Administrators (ADs) Minerva Sansano and Ray Santianez and stated the purpose of this visit. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure of the facility.

The facility is a single level structure and licensed for capacity of six non-ambulatory of which one may be bedridden; and has an approved hospice waiver for six. For this visit there was one resident under hospice care.

At 9:47 AM, LPA toured the interior and exterior portions of the facility with AD Santianez. There were one shared and four private resident's rooms; and one staff room. Resident's rooms were provided with adequate furniture, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were observed to be operational. Bathrooms were provided with grab bars, non-skid floor mats, and hot water was measured at 116 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. Exterior portion of the facility included a pool feature with no water was enclosed by steel fence inaccessible to residents in care. Patio furniture was observed in good repair. Exterior exit gates were self closing and self latching. LPA interviewed the staff and residents. LPA offered consultation on best practices in facility documentation.

For this visit, facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with ADs Sansano and Santianez; and copies of this report, were left in the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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