306006102-7-21-2022-22-AS-CDPO-CGJNS6-20220721104236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006102
Report Date: 07/21/2022
Date Signed: 07/21/2022 10:42:46 AM

Document Has Been Signed on 07/21/2022 10:42 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ATRIA SENIOR HOMES, INC.		FACILITY NUMBER:	306006102
ADMINISTRATOR:	CARRILLO, ROWENA MARANTAL		FACILITY TYPE:	740
ADDRESS:	24272 LYSANDA DRIVE		TELEPHONE:	(213) 281-1439
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 0	DATE:	07/21/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Facility Administrators - Rowena Marantal-Carrillo and Jireh Joy Mandap		TIME COMPLETED:	10:50 AM

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Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an announced pre-licensing visit and was greeted and granted entry by Facility Administrators (AD) Rowena Marantal-Carrillo and Jireh Joy Mandap at 9:11 AM. LPAs observed the Administrator's Certificate for Rowena Marantal-Carrillo which expires on 6/24/2023 and is posted in the entrance of the facility. AD Mandap has an Administrator’s certificate that expires on 9/26/2022.

LPAs De Perio and Marin toured the facility with AD Carrillo and AD Mandap and observed the following:

Structure: Facility is a single level structure. On January 22, 2022, The Orange County Fire Authority granted a fire clearance for a capacity of six residents of which five may be non-ambulatory and 1 may be bedridden. There are a total of 5 bedrooms, which there are 4 private rooms and 1 shared bedroom. There is a garage that is utilized as a staff office.

Resident Bedrooms: All five bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 120.0 degrees Fahrenheit.

Linens and Hygiene Supplies: Adequate supply of linens is stored in the bathrooms and in the garage.

Posters, Emergency Phone Numbers, Exit Plan: LPAs observed the COVID-19 precautionary signs posted, along with the PUB475 "See Something, Say Something" poster. Emergency disaster plan is posted in the entrance of the facility.

Continued on Page 2.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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: ATRIA SENIOR HOMES, INC.	FACILITY NUMBER: 306006102
	VISIT DATE: 07/21/2022

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Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Facility had back-up emergency food and water supply, in the kitchen and in the garage.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide were tested and operational.

Alarms: There are auditory alarms located on each door and all were tested and operational.

Fire Extinguisher: Fully charged, mounted, and located in the kitchen.

Appliances: Stove is a four-burner induction stove, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage.

Toxins: Locked and inaccessible to residents.

Medications, PPE First-Aid Kit and Manual: LPAs observed that First Aid Kit had all the required components. Medications were locked in a cabinet located in the kitchen. Facility had an adequate supply of PPE located in the garage.

Backyard: No bodies of water were observed. There is a locked shed in the backyard that is used to store tools. There are two exit gates in the backyard and both are self-closing and self-latching.

Resident and Staff Files: Records were kept in a locked cabinet located in the staff office.

Recreational Activities: The facility has activities that commensurate with plan of operation.

Continued on Page 3.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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: ATRIA SENIOR HOMES, INC.	FACILITY NUMBER: 306006102
	VISIT DATE: 07/21/2022

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LPAs De Perio and Marin verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Carrillo and AD Mandap. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA Marin reviewed the Component III with AD Carrillo and AD Mandap.

Per interviews, Licensee / Administrator stated that theey are not planning to advertise for special dementia program for this facility as of this time.

Prelicensing visit and Component III are now complete. LPAs will provide copy of this report to Centralized Applications Bureau for review and final determination of the application.

LPA De Perio conducted an exit interview with AD Carrillo and AD Mandap and a copy of this report was provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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