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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000910
Report Date: 03/30/2026
Date Signed: 03/30/2026 03:33:38 PM

Document Has Been Signed on 03/30/2026 03:33 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: 4DATE:
03/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:David MolinaTIME VISIT/
INSPECTION COMPLETED:
04:05 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. The facility is a single story home with 7 bedrooms (1 bedroom is for staff), 6 bathrooms, living room with a fireplace, kitchen, dining room and a family room with a fireplace. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 3. 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 last fire drill was conducted on March 12, 2026. LPA observed the kitchen is clean and organized. LPA observed the kitchen stove has the knobs removed for safety. 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 6 resident rooms had the required furnishings. LPA observed all 6 resident bedrooms are clean and organized. Hot water measured 106.7 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 observed extra linens and blankets stored in the pantry in the hallway. LPA observed a 3 day emergency food and water supply stored in the hall pantry. 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. All 4 staff had the required training and CPR/First Aid training. No obstacles or hazards observed inside or outside of the facility.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: VALLEY RESIDENTIAL ELDERLY CARE
FACILITY NUMBER: 306000910
VISIT DATE: 03/30/2026
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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.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC809 (FAS) - (06/04)
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