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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006101
Report Date: 03/06/2025
Date Signed: 03/06/2025 10:33:55 AM

Document Has Been Signed on 03/06/2025 10:33 AM - 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:HEAVENLY HOME, THEFACILITY NUMBER:
306006101
ADMINISTRATOR/
DIRECTOR:		WULFESTIEG, MICHELLEFACILITY TYPE:
740
ADDRESS:24552 MOSQUERO LNTELEPHONE:
(714) 404-0553
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Michelle Wulfestieg- Administrator
Kyshawna Owensby- House Manager		TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Vanessa Rosales followed by Caregiver Denise Hyde and explained the reason for the visit. Administrator (Admin) Michelle Wulfestieg arrived on premise to assist with the inspection. Administrator Wulfestieg has a valid administrator's certificate expiring on April 21, 2025.

The facility is a single story structure and is licensed to operate for bedridden residents and has a hospice waiver for six residents. During the tour of the physical plant, LPA observed five resident bedrooms and two resident bathrooms. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 113.0 and 112.8 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA observed sufficient emergency food and water. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. Both exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was mounted and purchased on January 14, 2025 per review of the purchase receipt. The auditory devices and dual functioning smoke/carbon monoxide detectors were tested and operational.

Emergency evacuation drills are conducted quarterly. Last known drill was conducted on January 14, 2025 per review of the log. The first aid kit contains all necessary elements. The facility land line number, (949) 770-7243, was tested and remains available. The liability insurance is valid expiring on July 1, 2025. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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: HEAVENLY HOME, THE
FACILITY NUMBER: 306006101
VISIT DATE: 03/06/2025
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LPA conducted a file review of all residents and one staff. No discrepancies noted. Medications were audited. Documentation errors observed. Interviews were conducted.

The following items were addressed during the exit interview: to assemble the emergency supplies and amend the Emergency Disaster Plan (LIC610D), to ensure a record of each dose is maintained properly, and to maintaining a log when reconciling the medications.

Based on the observations made during today's visit, no deficiencies are being cited. Advisory Notes (LIC9102s) are also being issued.

An exit interview was conducted Administrator Michelle Wulfestieg, and a copy of this report and the LIC9102s were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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