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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006237
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:56:53 AM

Document Has Been Signed on 11/17/2022 10:56 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:ASPEN VILLA IIFACILITY NUMBER:
306006237
ADMINISTRATOR:ALAMOUTINIA, MARYAMFACILITY TYPE:
740
ADDRESS:25411 CHAMPLAIN ROADTELEPHONE:
(949) 648-9205
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 0DATE:
11/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maryam AlamoutiniaTIME COMPLETED:
11:20 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 09/06/22.

Structure:
The facility is a one story house with an attached garage with 5 resident bedrooms, 3 full bathrooms, 1 TV room, a kitchen. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit walkway on the side of the house with covered patio seating for the residents.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Bedrooms Residents:
Bedrooms are for 0 ambulatory, 5 non-ambulatory, and 1 bedridden resident. Bedrooms will accommodate 6 residents with 4 private rooms and 1 shared room accommodating two clients. Bedrooms 1 and 5 have a full bathroom.

Bedrooms Staff:
Single story building located in back yard designated for awake-staff.

Continued on LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ASPEN VILLA II
FACILITY NUMBER: 306006237
VISIT DATE: 11/17/2022
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Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in each individual bedroom in storage closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with surplus goods stored in attached garage.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Electric four-burner stove, single oven, 1 refrigerator, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked underneath kitchen sink and in attached garage.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures 120.2 Fahrenheit degrees in resident restrooms and common bathroom.

Continued on LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ASPEN VILLA II
FACILITY NUMBER: 306006237
VISIT DATE: 11/17/2022
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Medications, First-Aid Kit & Book:
Medication and First Aid kit stored in locked medication storage closet.

Resident & Staff Files:
Records will be kept in locked medication storage closet.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.

Fire clearance:
Was approved on 10/20/22.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facility.

Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first resident. This notification may be done by phone, email or fax.

Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3