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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006103
Report Date: 03/21/2022
Date Signed: 03/22/2022 07:29:03 AM

Document Has Been Signed on 03/22/2022 07:29 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:CASA FRANCESCAFACILITY NUMBER:
306006103
ADMINISTRATOR:OLIVA, MARIZAFACILITY TYPE:
740
ADDRESS:2942 CALLE GRANDE VISTATELEPHONE:
(949) 240-6889
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 6CENSUS: 4DATE:
03/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mariza OlivaTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia made an announced visit to conduct a pre-licensing inspection. LPAs identified themselves and discussed the purpose of the visit with Administrator/ Licensee Mariza Oliva. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 10/15/2021 for a capacity of five non-ambulatory residents and 1 bedridden. Facility has a screening area in the entrance of the facility and LPAs self screened upon entry. LPAs observed covid signage at entrance to facility. LPAs observed the PPE supply. There are four residents in care during today's visit.
LPAs Lyman and Tapia along with Licensee/ Administrator toured the facility at 9:15 AM and observed the following:
Structure: Facility is a one story, 5 bedroom, 2 bathroom house with an unattached garage and a tan exterior. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms as well as hand washing signs posted. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in facility office adjacent to the entrance. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 107.3 and 108.7 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including a first aid guide. Medication is stored and locked in a locked cabinet. CONTINUED ON LIC 809C DATED 03/21/2022
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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: CASA FRANCESCA
FACILITY NUMBER: 306006103
VISIT DATE: 03/21/2022
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Facility does not use a medication administration record however facility audits medications weekly..Resident & Staff File: Records are stored in a secured file cabinet in the office. Reading Material, Games, and Equipment: LPA observed activities such as coloring books. Facility provides exercise and music therapy..Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for five non-ambulatory and one bedridden resident on 12/13/2021.

During the visit, LPA observed the following:
  • the French sliding door in office is dirty. Please clean.
  • Kitchen cupboards are dirty and have paint chipping on them. Please clean/ repair.
Licensee to complete corrections by 04/04/2022.


Component III waived during the visit. Licensee is currently licensed for other facilities. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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