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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006031
Report Date: 03/04/2025
Date Signed: 03/04/2025 02:46:05 PM

Document Has Been Signed on 03/04/2025 02:46 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:PORT MINOAFACILITY NUMBER:
306006031
ADMINISTRATOR/
DIRECTOR:		ROCHE, RYANFACILITY TYPE:
740
ADDRESS:25601 MINOA DRIVETELEPHONE:
(949) 916-9228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ryan Roche and Scott MessickTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which one may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 1 resident on hospice. Administrators (ADs) Ryan Roche Scott Messick arrived shortly to conduct facility tour. Each AD has a valid certificate that expires on 12/1/2025. AD provided updated liability insurance that expires on 9/15/2025.

LPA along with ADs toured the facility at 12:50 PM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, staff room, living room, dining room, and kitchen as well as 2 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 114.6 degrees F and 116.7 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguisher was fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill was conducted on 12/30/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of games, exercise, and music therapy. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. LPA observed the emergency food and water supply. LPA reviewed five resident files and two staff files.
CONTINUED ON LIC 809C DATED 3/4/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: PORT MINOA
FACILITY NUMBER: 306006031
VISIT DATE: 03/04/2025
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All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked closet.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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