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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006081
Report Date: 01/07/2022
Date Signed: 01/07/2022 02:56:50 PM

Document Has Been Signed on 01/07/2022 02:56 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:GOOD MORNINGS HOME CAREFACILITY NUMBER:
306006081
ADMINISTRATOR:SHOGA, CYNTHIAFACILITY TYPE:
740
ADDRESS:25735 CERVANTES LANETELEPHONE:
(949) 492-3532
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
01/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cynthia ShogaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to commence an announced Pre-licensing visit. Upon arrival, LPA met with Cynthia Shoga. Mrs.Shoga will be the designated Administrator.
An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 11/4/21 for a capacity of 6. Capacity will be 5 non-ambulatory, 1 ambulatory and 1 bedridden resident. The Orange County Fire Authority conducted a Fire Safety Inspection on 11/8/21 and granted a fire clearance. Room #4 was approved for a bedridden resident and #6 was approved for ambulatory residents only. The facility is not approved for locked perimeters. The facility will be a change of location and there were 4 residents present. A tour of the physical plant was conducted inside and out at approximately 1:30pm and the following was observed:
Structure:
Facility is a one story house with 6 bedrooms and 4 full bathrooms. Bedroom #1, #2, #3, #4, #5 and #6 are designated as resident rooms. There is also a living room, dining area, laundry room and kitchen. There is a staff resting room just outside the storage closet near Room #1. There are fountains in the front and backyard that meet Title 22 regulation. Shade was provided on the patio. COVID19 mitigation procedures were also discussed with the Applicant. The discussion included: Social distancing, mask requirements, temperature checks, as well as the posting of signs. A hand sanitizing station was present for visitors and staff at the front door. Applicant stated that she has plenty of PPE(gloves, masks, hand sanitizer)
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms accommodate residents' furnishings and meet Title 22 regulation at this time.
Bathrooms:
Bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOOD MORNINGS HOME CARE
FACILITY NUMBER: 306006081
VISIT DATE: 01/07/2022
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Linens and Hygiene Supplies:
Adequate supply of linens was observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster, Personal Rights and See Something Say Something posters were posted. Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables are stored in the kitchen and pantry and includes fruits and vegetables. LPA observed food in pantry.
Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Appliances:
Refrigerator/freezer and microwave were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Locked and inaccessible to residents
Water Temperature:
Water Temperature was measured at degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide is stored with resident medications. Medication will be stored and locked in the facility living area.
Resident and Staff Files:
Records will be kept locked for privacy.
Component III
Component III was conducted.

The Pre-licensing is complete and this facility has no deficiencies. Corrections to the sketch will be provided.

The License will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted with Cynthia Shoga and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
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