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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006101
Report Date: 01/18/2024
Date Signed: 01/18/2024 07:36:51 PM

Document Has Been Signed on 01/18/2024 07:36 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: 5DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Michelle Wulfestieg- Adminisrator
Shundra Moss- Licensee
Kyshawna Owensby- House Manager		TIME COMPLETED:
07:55 PM
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On today's date, Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to conduct the Required -1 Year Inspection. LPA stated the purpose of the visit to House Manager (HM) Kyshawna Owensby and Administrator (Admin) Michelle Wulfestieg and Licensee Shundra Moss arrived to assist with the inspection. LPA observed a total of 5 residents in care and three staff.

LPA conducted a tour of indoor/outdoor area of the facility accompanied by HM Owensby and Admin Wulfestieg and the following were observed: This is a single story facility comprised of five resident bedrooms and two resident bathrooms, staff office, backyard, and a two car garage. LPA observed the backyard has patio cover for shading with outdoor furniture. The five resident bedrooms are spacious and can easily accommodate the residents' furnishings. Furniture for each resident bedrooms were inspected. The bathrooms were clean, faucets, and toilets were operational. The hot water temperature reading measured at 118.9 and 119.7 degrees Fahrenheit. There were sufficient supply of clean linens. LPA observed a 2-day supply of perishables and a 7-day supply of non-perishable food as required per regulations. The carbon monoxide and smoke detectors were tested and operational. LPA observed medications were centrally stored and secured. Administrator acknowledged to pay the upcoming licensing fee due March 30, 2024. LPA reviewed the five resident files and three staff files, interviewed one out of the five residents and three out of the three staff.

LPA offered consultation for the following: to have the fire extinguisher serviced or purchased annually, to correctly dispense the medication corresponding with the calendar date, and to correctly document on the bubble pack when the medication refill started.

Based on the observations made during today’s inspection, no deficiencies are being cited during today's visit. Two Technical Violations (TVs) will be issued. See the attached LIC9102s.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/18/2024
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An exit interview was conducted with Administrator Michelle Wulfestieg, Licensee Shundra Moss, House Manager Kyshawna Owensby, and a copy of this report including the TVs were issued at the end of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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