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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006275
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:43:04 PM

Document Has Been Signed on 04/17/2024 03:43 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:EPIC ASSISTANCE CARE HOME 3FACILITY NUMBER:
306006275
ADMINISTRATOR/
DIRECTOR:
AZIZA, SIMONAFACILITY TYPE:
740
ADDRESS:25466 VIA ESTUDIOTELEPHONE:
(949) 543-7698
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Simona AzizaTIME VISIT/
INSPECTION COMPLETED:
03:57 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Simona Aziza and explained the reason for the visit. The facility is a single story home with 6 bedrooms (1 bedroom is for staff only), 5 bathrooms, kitchen, living room with a fireplace that is screened, dining room and an attached 2 car garage that is used for storage. LPA and Administrator toured the facility. The Administrator's certificate expires 12/2/2024. LPA observed the PUB 475 poster (see something, say something poster) is posted in the entry way of the facility. LPA observed the kitchen is clean and organized. The stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The knives and sharp objects are kept secured in a kitchen drawer inaccessible to residents. LPA observed the medications are kept locked in a closet adjacent to the dining room. LPA observed the fireplace in the living room is screened. There is a TV in the living room for residents to watch. LPA observed all fire extinguishers are fully charged. LPA and Administrator toured the resident rooms. LPA observed the resident rooms had all the required furnishings and linens. LPA observed all the resident bathrooms were clean and operational. Hot water measured between 106.9 and 170.0 degrees Fahrenheit in all bathrooms. LPA and Administrator toured the backyard. No bodies of water observed. There is shaded seating area with chairs and an umbrella for residents to sit outside. There is a storage shed in the backyard used for old furniture and wheelchairs. The exit gate is operational and self-closing. No obstacles or hazards observed in the backyard. LPA inspected the garage. The garage is used for storage and inaccessible to residents. Smoke detectors/carbon monoxide detectors tested operational. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA reviewed 3 staff files no discrepancies observed. LPA reviewed resident files and medication. No discrepancies observed. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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