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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000910
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:06:02 PM

Document Has Been Signed on 03/11/2025 12:06 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:VALLEY RESIDENTIAL ELDERLY CAREFACILITY NUMBER:
306000910
ADMINISTRATOR/
DIRECTOR:
ELVIRA GOMEZFACILITY TYPE:
740
ADDRESS:24911 ADELANTOTELEPHONE:
(949) 249-9092
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:David MolinaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Administrator David Molina. David Molina's Administrator's Certificate expires on September 9, 2026. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the living room. The PUB 475 poster is visible from the front door. The facility is a single story home with 6 bedrooms, 5 bathrooms, living room with a fireplace, kitchen, dining room and a family room with a fireplace and an attached two car garage. The facility Administrator reported to the LPA the facility is undergoing a remodel. The facility is converting the garage into a staff living quarters and adding an additional bathroom to a resident room. The facility has emailed the LPA the new facility sketch and request for construction approval. The doors to the rooms undergoing remodeling are secured and pose no danger to the residents. The last fire drill was on March 5, 2025. LPA observed the kitchen is clean and organized. There is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the stove lights unassisted. Knives are kept locked in a kitchen drawer. Cleaning supplies and chemicals are kept locked under the kitchen sink. LPA observed all 5 resident rooms had the required furnishings. LPA observed all 5 resident bedrooms are clean and organized. Hot water measured 111.7 degrees Fahrenheit in the shared bathroom in the hallway next to the living room. Smoke detectors/carbon monoxide detectors tested operational. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA and Administrator toured the garage. LPA and Administrator toured the backyard. LPA observed a raised fountain in the backyard. There is a covered seating area with a table and chairs. Both exit gates on each side of the house are latched and self closing. No obstacles or hazards observed in the backyard. LPA reviewed all 5 resident medications. No discrepancies observed. LPA reviewed 5 resident files, no discrepancies observed. LPA reviewed 4 staff files, no discrepancies observed. All 4 staff had the required training and CPR/First Aid training. No obstacles or hazards observed inside of the facility. LPA consulted with Administrator concerning reporting requirements. No deficiencies observed during the visit. No deficiencies are being cited as a result of the visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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