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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006285
Report Date: 04/30/2024
Date Signed: 04/30/2024 05:32:15 PM

Document Has Been Signed on 04/30/2024 05:32 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:PORT ALICIAFACILITY NUMBER:
306006285
ADMINISTRATOR/
DIRECTOR:		MESSICK, SCOTTFACILITY TYPE:
740
ADDRESS:25341 DIANA CIRCLETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Ryan Roche & Scott Messick- Licensees/AdministratorsTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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On April 30, 2024, at 2:05pm, Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim conducted an unannounced Required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs Cho and Kim met with Licensees/Administrators (Admins) Scott Messick and Ryan Roche and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and maintains six (6) hospice waivers. The facility is a single-story structure located in a residential neighborhood which consists of the following: five (5) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, two-car garage, outdoor patio area, and a laundry room which is being currently renovated into a bedroom. Per review of records, facility does not have an approved fire clearance for the renovated room, however facility maintains a building permit which was provided to LPAs during the visit.

LPAs toured inside and outside of the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. . All bedrooms were inspected for: Resident Rooms #1-5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 115.5 and 113.5 degrees Fahrenheit. A comfortable indoor temperature of 77 degrees Fahrenheit was maintained in the facility. LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and inaccessible to the residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has two fire extinguishers that are charged and serviced on 11/01/2023. Smoke/carbon monoxide detectors were tested and operable. The facility conducted a Fire/Safety Drill on 01/14/2024. A working telephone (949-859-8391) remains available. First Aid Kit contained all the necessary elements.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 05:32 PM - It Cannot Be Edited


Created By: Jessica Cho On 04/30/2024 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PORT ALICIA
FACILITY NUMBER: 306006285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations and record review, the licensee did not comply with the section cited above in which the facility did not maintain an approved fire clearance for the laundry room that is being converted into a bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Please submit a copy of the original and the new facility sketches indicating the changes and submit a check in the amount of $25.00 payable to California Department of Social Services.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


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: PORT ALICIA
FACILITY NUMBER: 306006285
VISIT DATE: 04/30/2024
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During the visit, LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The 'See Something Say Something" (PUB475) was maintained at 16"x26" which did not meet the required measurements of 20"x26."

LPAs conducted an audit of six residents' service files, and two staff personnel files which were in order and completed. LPAs conducted two staff interviews. No resident interviews were conducted due to residents being occupied with their afternoon activities. Medications were audited for six residents and no discrepancies noted for six out of the six residents.

Based on the observations made by the LPAs, one deficiency is being cited today as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. An Advisory Note is being issued, and an immediate civil penalty is being assessed. See LIC421IM.

An exit interview was conducted with Licensees/Administrators Ryan Roche & Scott Messick, and a copy of this report along with the LIC809C, LIC809D, LIC421IM, and the appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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