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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006681
Report Date: 02/21/2025
Date Signed: 02/21/2025 10:01:33 AM

Document Has Been Signed on 02/21/2025 10:01 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:GRANNY'S PLACE #11FACILITY NUMBER:
306006681
ADMINISTRATOR/
DIRECTOR:		NESBITT, MICHELLEFACILITY TYPE:
740
ADDRESS:24111 OLIVERA DRIVETELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Administrator Michelle NesbittTIME VISIT/
INSPECTION COMPLETED:
10:16 AM
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Licensing Program Analyst (LPA) Brandon Lopez made an announced visit to the facility for the purpose of conducting a Pre-licensing Inspection. LPA met with Administrator (AD) Michelle Nesbitt. LPA observed that Michelle Nesbitt has a valid Administrator certificate which expires on April 11, 2026.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of six non-ambulatory residents was received by Community Care Licensing (CCL) on November 8, 2024. This is a change of ownership with four residents already in care. The facility received an approved Fire Clearance by Orange County Fire Authority Inspector Alex Vega on January 15, 2025.

The facility is a one story home with six private resident bedrooms, one staff room, six resident bathrooms, two of which are shared, a kitchen, a dining room, a living room, and an attached two car garage. LPA accompanied by AD conducted a tour of the interior portion of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the six private resident bedrooms. The six resident bedrooms are clean and free of hazards. LPA observed all six resident bedrooms have the required furnishings of a bed, a chair, and chest of drawers, and a lamp. Resident beds have clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected all six resident bathrooms. Resident bathrooms are clean. Bathrooms were equipped with grab bars and non-slip floor mats. Faucets and toilets were operational. Hot water temperature measured between 114.2 and 115.1 degrees Fahrenheit. LPA observed Oxygen signs are posted in the appropriate areas. LPA observed the staff room is kept locked and inaccessible to residents in care.

LPA observed the facility has a minimum two day perishable and seven day non-perishable food supply on hand in the kitchen. LPA observed the four burner gas stove, the refrigerator, and the microwave to be clean and operational. LPA observed the four burner gas stove lights unassisted. LPA observed knives and sharps to be stored in a locked kitchen cabinet. CONTINUED ON 809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 #11
FACILITY NUMBER: 306006681
VISIT DATE: 02/21/2025
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LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the kitchen and it was observed to be charged and purchased on May 1, 2024. LPA observed a First Aid Kit mounted on the wall in the kitchen. The First Aid kit was observed to have all the required components.

LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. Auditory exit alarms tested operational for all exits. The centrally stored medication is located inside a locked closet in the resident hallway. LPA observed the facility has card games, art and craft materials, and reading books for resident use stored in the dining room. LPA observed an internet device for dedicated resident use to be stored in the dining room. LPA observed residents and staff records are kept in a locked closet in the resident hallway but the AD will transition all files to electronic storage. The door leading to the attached two car garage is kept locked and inaccessible to residents in care. LPA observed the two car garage is used for storage and laundry. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and the AD conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of obstructions and hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the east side and west side of the facility are self-latching and can be opened in an evacuation. There is a storage shed located in the backyard which is kept locked and inaccessible to residents in care. There are no bodies of water located on the premises.

Component III was completed with the AD which provided information about how to operate the facility within compliance and reporting requirements. The AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted and a copy of this report was provided to Administrator Michelle Nesbitt.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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