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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006541
Report Date: 07/02/2024
Date Signed: 07/02/2024 10:34:07 AM

Document Has Been Signed on 07/02/2024 10:34 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DELZEN'S PLACEFACILITY NUMBER:
306006541
ADMINISTRATOR/
DIRECTOR:		SAN DIEGO, JONATHANFACILITY TYPE:
740
ADDRESS:24522 VANESSA DR.TELEPHONE:
(949) 258-2063
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
07/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee-Diana Manalo, Administrators-Jonathan San Diego and Delia PardoTIME VISIT/
INSPECTION COMPLETED:
10:48 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Licensee Diana Manalo and Administrators Jonathan San Diego and Delia Pardo. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by Community Care Licensing (CCL) on 3/26/2024.

The facility is a one-story home with five resident bedrooms, two bathrooms, living room, dining room, kitchen, laundry room, caregiver room, backyard and 2-car garage.



Resident Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened.

All bathrooms have working plumbing and designated hand washing posters. Hot water measured 105 and 120 degrees Fahrenheit in the Resident bathrooms.

LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. The fire extinguishers were purchased on 4/8/2024. Medication and First-Aid Kit will be locked in a cabinet near the living room. Resident & Staff Files will be locked with medication.

LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in the garage. Linens are store in hallway closets.

Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review.
LPA observed other necessary postings near the living room and dining room.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DELZEN'S PLACE
FACILITY NUMBER: 306006541
VISIT DATE: 07/02/2024
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The fire clearance was approved by a fire inspector of Orange County Fire Authority on 4/9/2024.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational.

Operational appliances include a gas stove, oven, one refrigerator, freezer, dishwasher, microwave, washing machine and dryer.

LPA provided the Component III presentation to offer information and resources regarding maintaining facility compliance.

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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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