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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006107
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:26:57 PM

Document Has Been Signed on 08/03/2022 02:26 PM - 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: 6DATE:
08/03/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ryan FiskTIME COMPLETED:
02:50 PM
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On 08/03/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Villa Regina 2. The initial purpose of today's visit was to conduct a Required 1 Year visit to Villa Regina 2. It was determined upon entry that Villa Regina 2 no longer exists and the facility changed its name to Ohana Care 5. For this reason, LPA Cho conducted a Post Licensing visit to Ohana Care 5. At 1:27pm, LPA Cho was allowed entry into the facility after completing the Coronavirus 2019 (COVID-19) screening procedure and met with Caregivers Evelyn Austria and Welson Turambi. Caregiver Mientje Noija was also present and resting in the private staff bedroom. Licensee/Administrator (Admin) Ryan Fisk entered the facility around 1:50pm and assisted with the tour. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice waiver for four residents. There are currently six residents living in the facility of which two are receiving hospice services.

At 1:43pm, LPA Cho conducted a tour of the physical plant along with Admin Fisk and Caregiver Austria. The single story home consists of four resident bedrooms with two resident bathrooms. There is one staff bedroom. The facility also has a living room, family room, dining area, kitchen, laundry room, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 117.6 degrees Fahrenheit in the Bathroom #1 and 119.1 degrees Fahrenheit in Bathroom #2.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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: 08/03/2022
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LPA Cho inspected the kitchen along with Caregiver Austria. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho along with Admin Fisk toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and there were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPEs.

LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. A facility tablet is available for residents upon request.



No resident or staff files were reviewed at the time of this visit. The facility did not meet the Infection Control Plan requirement due on June 30, 2022. LPA provided the PIN pertaining to the Infection Control Plan while conducting a Post Licensing visit at Ohana Care 2. Licensee agrees to submit the Infection Control Plan by 08/08/2022.

Licensee/Administrator Ryan Fisk was reminded of the importance of staying abreast with CCLD’s COVID-19 guidance and additional information by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: ccld.ca.gov.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensee/Administrator Ryan Fisk, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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