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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006101
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:12:57 PM

Document Has Been Signed on 03/28/2022 03:12 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:HEAVENLY HOME, THEFACILITY NUMBER:
306006101
ADMINISTRATOR:WULFESTIEG, MICHELLEFACILITY TYPE:
740
ADDRESS:24552 MOSQUERO LNTELEPHONE:
(714) 404-0553
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michelle Wulfestieg, AdministratorTIME COMPLETED:
03:35 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting the pre-licensing verifications required for an initial application.
At approximately 2:00pm, LPA was greeted upon arrival by the prospective administrator Michelle Wulfestieg and granted entry. Facility is a one-story house with five (5) bedrooms assigned to residents, including a shared bedroom. There are currently no residents in care.

LPA accompanied by administrator started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents, with the exception of beds which will be provided by the various hospice providers as detailed in the facility's plan of operations. Bathrooms are equipped with non-slip maTs and grab bars, as well as hand-washing signs. Hot water is measured to be 115 degrees in the bathrooms and kitchen. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as a carbon monoxide detector. The facility is also equipped with a functional sprinkler system. The exterior of the physical plant is free of clutter and debris. Perimeter gates are self-latching and do not require keys to open.

An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply. A sample menu is displayed in the kitchen. A sufficient supply of PPE is also stored in the attached garage. Toxic substances are stored in a lockbox underneath the kitchen sink. Laundry detergent and other cleaning supplies are under lock in the garage.

(CONTINUED ON FORM LIC809C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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: HEAVENLY HOME, THE
FACILITY NUMBER: 306006101
VISIT DATE: 03/28/2022
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A check-in station is observed for the documentation of temperature checks for visitors, residents and staff. Medication assigned to each client will be centrally stored in a locked medication cart itself located in a locked closet. Staff and resident files are stored on the premises in the staff office. A sample resident file is presented by licensee and observed to include all required elements.

An emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted also.

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The Component III has been reviewed with licensee and administrator. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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