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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006350
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:29:44 AM

Document Has Been Signed on 02/29/2024 11:29 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ARBOR ON THE GREENFACILITY NUMBER:
306006350
ADMINISTRATOR:MARK FISK / BRIGITTE FISKFACILITY TYPE:
740
ADDRESS:24182 PASEO DEL CAMPOTELEPHONE:
(949) 998-9191
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 0DATE:
02/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald, Brigitte, Erin, and Mark FISKTIME COMPLETED:
12:00 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. LPA arrived at facility was greeted and granted entry. LPA met with Donald, Brigitte, Erin, and Mark FISK, applicants and explained the visit.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (2) ambulatory, (1) non-ambulatory, and (3) bedridden resident was submitted to CCL on 05/01/23.

Structure:
The facility is a one story house with a garage with 6 resident bedrooms, 1 staff bedroom, 7 full bathrooms, a living rooms, a dining room, and a kitchen. The resident’s bedrooms are all private and are spacious, will easily accommodate the resident’s furnishings. There is a back yard with a patio and one exit walkway on one side of the house with seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 6 private rooms. All 6 resident bedrooms have a full bathroom. Bedrooms Staff: Bedroom #4 is designated for staff. Bathrooms: Facility has seven full bathrooms. All bathrooms have a working toilet, wash basin, walk in shower.Linens & Hygiene Supplies: Adequate supply of linen in closet storage.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. Smoke Detectors: Smoke detectors and carbon monoxide alert

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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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: ARBOR ON THE GREEN
FACILITY NUMBER: 306006350
VISIT DATE: 02/29/2024
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systems are hardwired, were tested, and found operational. Fire extinguishers mounted in kitchen and resident bedroom hallway and charged. Appliances: Electric five burner stove, single oven, refrigerator, microwave, dishwasher, 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 in the laundry unit and garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 116.6 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and First Aid kit stored in locked storage closet. Resident & Staff Files: Records will be kept locked in a storage cabinet. 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 12/19/23. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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