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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006105
Report Date: 05/19/2022
Date Signed: 05/19/2022 09:53:09 AM

Document Has Been Signed on 05/19/2022 09:53 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:OHANA CARE 4FACILITY NUMBER:
306006105
ADMINISTRATOR:FISK, RYAN & BRIGETTEFACILITY TYPE:
740
ADDRESS:24351 REGINA ST.TELEPHONE:
(949) 989-1975
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ryan Fisk, AdministratorTIME COMPLETED:
10:20 AM
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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 a change of ownership.
At approximately 9:00am, LPA was greeted upon arrival by the current and prospective licensee Ryan Fisk and granted entry after being screened for COVID-19 symptoms. Facility is a one-story house with an attached garage. Six (6) bedrooms are assigned to residents. Four (4) residents are currently present including three (3) receiving hospice care. The residents are observed relaxing in the common area and appear clean and well taken care of.

LPA and Administrator started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents. The three (3) bathrooms used by residents are equipped with non-slip mats and grab bars. The hot water temperature is measured to be 115 degrees in two of the residents' bathrooms. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as carbon monoxide detectors in the hallway and in the main area. The exterior of the physical plant is also free of clutter and debris. No gates are present at the sides of the house on the noted evacuation routes pending upcoming installation of a gate. No bodies of water are present on the premises and water features are fully secured.

An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply. Weekly nutrition plans are displayed in the kitchen and rotated between the facilities operated by licensee. A sufficient supply of PPE is also stored in the medication cabinet. Cleaning supplies and toxics are stored in a cabinet in the laundry room which is always kept locked by a combination doorknob. Medication assigned to each client is centrally stored in bubble packs and locked. Staff and resident files are stored on the premises and are verified to included all necessary documents.

CONTINUED ON FORM LIC 809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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: OHANA CARE 4
FACILITY NUMBER: 306006105
VISIT DATE: 05/19/2022
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CONTINUED FROM FORM LIC 809

Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted to Community Care Licensing (CCL).

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. As the prospective licensee already operates the facility under a different business name, the Component III has been waived. 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: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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