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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006107
Report Date: 04/07/2022
Date Signed: 04/07/2022 09:53:35 AM

Document Has Been Signed on 04/07/2022 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 5FACILITY NUMBER:
306006107
ADMINISTRATOR:FISK, RYAN & BRIGETTEFACILITY TYPE:
740
ADDRESS:24182 ADONIS ST.TELEPHONE:
(949) 989-1975
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
04/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ryan Fisk, Administrator
Brigitte Fisk, Adminstrator		TIME COMPLETED:
10:30 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 9:05am, LPA was greeted upon arrival by the current and prospective licensee Ryan Fisk and Brigitte Fisk and granted entry. Facility is a one-story house with an attached garage. Four (4) bedrooms are assigned to residents and one (1) bedroom is assigned to staff. Two (2) of the residents' bedrooms are shared and two (2) are single occupation. The current census is five (5) with three (3) residents currently on hospice.

LPA accompanied by administrator started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents. Two (2) bathrooms used by residents are equipped with non-slip mats and grab bars. Hot water is measured to be 124 degrees in the kitchen and 125 degrees in the bathroom. Licensee adjusted the temperature at the tank down during the visit. An ample supply of linen is available to residents. Centrally wired smoke detectors are present in each room and found to be operational as well as carbon monoxide detectors in hallways and in the main area. The facility is also equipped with a functional sprinkler system. The exterior of the physical plant is free of clutter and debris. The single perimeter gate is self-latching and easy to open in the eventuality of an evacuation.

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. A sufficient supply of PPE is also stored in the medication cabinet. Cleaning supplies and toxics are stored in cabinets in the laundry room which is always kept locked. Medication assigned to each resident is centrally stored in bubble packs and locked. Staff and resident files are stored on the premises. Two resident files are observed to include all required up-to-date documentation.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 5
FACILITY NUMBER: 306006107
VISIT DATE: 04/07/2022
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CONTINUED FROM LIC809

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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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