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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006108
Report Date: 03/17/2025
Date Signed: 03/17/2025 01:36:14 PM

Document Has Been Signed on 03/17/2025 01:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OHANA CARE 3FACILITY NUMBER:
306006108
ADMINISTRATOR/
DIRECTOR:		FISK, RYANFACILITY TYPE:
740
ADDRESS:24362 AUGUSTIN STTELEPHONE:
(949) 989-1975
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Ryan Fisk, administratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Brigitte Fisk was present on the premises. Ryan Fisk arrived later and also assisted with the visit. This is the facility's first annual visit with residents in place.

There are currently six residents in care, two of which is receiving hospice care. LPA observed residents relaxing in their respective bedrooms and in the facility's common living areas, as well as having lunch in the facility's dining room. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has six private bedrooms and one staff room in use by the awake night staff. There are four en-suite bathrooms and one shared bathroom throughout the facility.

Bedrooms appeared clean and sanitary. One bed is observed to be equipped with half rails. The hospice plan of care was reviewed and did not include an order for the postural supports which will be requested from the hospice provider. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars and slip mats. Hot water temperature measured at 109F and 111F in two separate bathrooms with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in the secure laundry area, along with cleaning supplies and the medication central storage. Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The attached garage is inaccessible to residents and is used as an administrative office by the licensee.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: OHANA CARE 3
FACILITY NUMBER: 306006108
VISIT DATE: 03/17/2025
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. There is no fencing around the facility, licensee additionally operates a licensed facility next door and both houses share backyards. There is a fence along the backyard's property line. Per the stated plan of operation, the outdoor space is systematically used under staff or family supervision. None of the currently admitted residents use the outdoor space independently. Advisory notes provided. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress.

LPA reviewed six resident records which included all necessary components. One physician report reviewed is dated November 2023 after a resident's provider resubmitted a prior assessment. An updated assessment will be conducted. Advisory note provided. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Oxygen is in use and a sign was placed accordingly during the visit. Advisory note provided. There are no bedridden residents present on the premises. LPA reviewed staff records for both caregivers present. Records were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
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