306006290-4-5-2023-22-AS-CGUZ-CQLNZD-20230405105410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006290
Report Date: 04/05/2023
Date Signed: 04/05/2023 10:54:18 AM

Document Has Been Signed on 04/05/2023 10:54 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:	MIMI'S SENIOR HOME		FACILITY NUMBER:	306006290
ADMINISTRATOR:	SANSANO, MINERVA		FACILITY TYPE:	740
ADDRESS:	24362 APHENA AVE		TELEPHONE:	(919) 317-0885
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	04/05/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Minerva Sansano		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Minerva Sansano. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 12/21/2022. Structure: The facility is a single-story house with six resident bedrooms, two bathrooms, living room, kitchen, dining room, laundry room, staff break room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room entrance area. There is a back yard with two exit gates, one on each side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked beneath the kitchen sink and in a locked storage cabinet in the garage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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: MIMI'S SENIOR HOME	FACILITY NUMBER: 306006290
	VISIT DATE: 04/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medications, First-Aid Kit & Book:
Medication will be stored in a locked closet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the dining room area.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility provides daily newspaper for reading. Leisure group activities such as nail painting and board games will be encouraged.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 02/14/2023. Special conditions noted “Bedroom #5: Bedridden. Bedroom #1-4, 6: non-ambulatory.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

Staff will not be living on site; the facility has one staff break room.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 113.9 degrees Fahrenheit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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: MIMI'S SENIOR HOME	FACILITY NUMBER: 306006290
	VISIT DATE: 04/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3