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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005965
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:59:40 PM

Document Has Been Signed on 10/10/2024 03:59 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:OHANA BOARD AND CAREFACILITY NUMBER:
306005965
ADMINISTRATOR/
DIRECTOR:		UJIMORI, TROYFACILITY TYPE:
740
ADDRESS:25422 PACIFICA AVETELEPHONE:
(949) 807-2336
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Troy Ujimori, licensee/administratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Samer Haddadin made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were greeted and granted entry by administrator Troy Ujimori after introducing themselves and stating the purpose of the visit.
LPAs accompanied by administrator conducted a tour of the physical plant and observed the following: the facility is a two-story home with an attached two-car garage. The house's second floor is accessible only through the garage and a locked door with a digital code on the handle and is only for use by facility staff. The first level has five bedrooms including a master bedroom which can be shared and four private bedrooms, in addition to a bedroom used by staff overnight. There are two bathrooms including the en-suite bath of the master bedroom. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational, however due to a plumbing intervention occurring due to a leak inside one of the bathrooms, the water temperature could not be measured during the present visit. An annual continuation visit will therefore be required. LPAs observed all beds have linen and blankets.

There are currently four residents admitted to the facility, none of which are receiving hospice care. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly but are not documented by staff and licensee as required by regulations. Consultation provided. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been maintained in 2024.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress are free of obstructions.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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: OHANA BOARD AND CARE
FACILITY NUMBER: 306005965
VISIT DATE: 10/10/2024
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CONTINUED FROM FORM LIC809

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPAs reviewed four resident files along with two staff files. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training and CPR training verified to be up to date.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three consultations provided.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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