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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006390
Report Date: 02/03/2025
Date Signed: 02/03/2025 12:47:35 PM

Document Has Been Signed on 02/03/2025 12:47 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:GRANNY'S PLACE #3FACILITY NUMBER:
306006390
ADMINISTRATOR/
DIRECTOR:		MALACA, ROCHELFACILITY TYPE:
740
ADDRESS:24695 DORIA AVENUETELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Michelle Nesbitt, administrator
Kimberly Arnett, Assistant Administrator
Jozef Springer, Executive Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator staff Michelle Nesbitt, Kimberly Arnett and Jozef Springer were notified of the visit via telephone and arrived later to assist with the visit.

There are currently six residents in care, none of which are receiving hospice care. LPA observed residents relaxing in their respective bedrooms and in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has four private bedrooms and one shared room assigned to a couple, in addition to a room for use by staff. There are two full bathrooms throughout the facility.

Bedrooms appeared clean and sanitary. Three beds are equipped with half rails. Physician orders for the postural support reviewed. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars and slip mats. Hot water temperature measured at 107.5F in two separate bathrooms with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure closet located in the dining area. The attached garage is inaccessible to residents and is used for storage and laundry, with an additional refrigerator/freezer present. Cleaning supplies are stored securely in the garage as well as under the kitchen sink and bathroom sinks.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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: GRANNY'S PLACE #3
FACILITY NUMBER: 306006390
VISIT DATE: 02/03/2025
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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. The perimeter gate on one side of the property is self-latching and can easily be opened in an evacuation. There is a fully fenced swimming pool on the premises, which has been emptied at the time of the visit.

LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Three resident interviews conducted during the visit. There are no bedridden residents present on the premises. LPA reviewed three staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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