306003841-1-26-2026-22-AS-JCHO-DQPVHA-20260126152650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003841
Report Date: 01/26/2026
Date Signed: 01/26/2026 03:26:59 PM

Document Has Been Signed on 01/26/2026 03:26 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:	A PERICLES ELDERLY CARE HOME		FACILITY NUMBER:	306003841
ADMINISTRATOR/ DIRECTOR:	LUIS GAITAN		FACILITY TYPE:	740
ADDRESS:	25822 PERICLES		TELEPHONE:	(949) 859-2811
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 5	DATE:	01/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Luis Gaitan- Administrator Lisa Gaitan- Administrator Concepcion Jimenez- House Manager		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On January 26, 2026, Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Administrator Luis Gaitan after introducing self and stating the reason for the visit. House Manager (HM) Concepcion Jimenez and Administrator Lisa Gaitan were present during today's inspection. Admin Luis has a valid certificating expiring May 6, 2027. The inspection is as follows: This is a single story property located in a residential neighborhood comprised of five resident bedrooms, one private staff bedroom, and two (2) resident bathrooms. Facility is not operating within the conditions and limitations specified on the license. Facility has an approved hospice waiver for four (4) and is exceeding the number of hospice residents that can be served at one time. There are five (5) residents receiving care from a hospice agency during today's visit where the 5th resident was admitted on January 23, 2026. LPA along with Caregiver Omar Escalante toured the interior portion of the facility. The facility is clean, sanitary, and in good repair. LPA inspected all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. The sliding doors are in good repair. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were available. The hot water temperature in the bathrooms measured at 119.4 and 117.4 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed two-day supply of perishables and seven-day supply of non-perishable food. In addition to the resident bedroom inspections, LPA inspected all common areas including the attached two car garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

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: A PERICLES ELDERLY CARE HOME	FACILITY NUMBER: 306003841
	VISIT DATE: 01/26/2026

NARRATIVE

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The exit gate is operational, and there were sufficient seating and shading in the patio area. There are no bodies of water on premise, and the fire place was screened. LPA observed the fire extinguisher was mounted, charged, and serviced on October 2, 2025. The indoor temperature remains at a comfortable range. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Facility maintains emergency food, water, and supplies (such as portable radios, flashlights, and batteries) in the medication closet. The 'See Something, Say Something' Poster (PUB475) was posted in the required size. The first aid manual was available.

LPA reviewed six of six resident and two personnel files in which no discrepancies were found. Medications were audited for two out of six residents. No discrepancies were found with medication administration. Staff training is up-to-date including CPR/First Aid. Present staff are background cleared and associated to the facility. Disaster drills of various emergency scenarios are conducted quarterly and documented as required.

Based on the observations made during today's visit, a deficiency is being cited.

An exit interview was conducted with Administrator Lisa Gaitan and House Manager Concepcion Jimenez, and a copy of this report including the appeal rights were provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2026 03:26 PM - It Cannot Be Edited

Created By: Jessica Cho On 01/26/2026 at 02:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A PERICLES ELDERLY CARE HOME	FACILITY NUMBER: 306003841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one out of five residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2026
	Plan of Correction
1 2 3 4	Administrators Luis and Lisa stated that a letter requesting hospice waiver increase from (4) to (6) with a copy of the resident roster will be submitted to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC809 (FAS) - (06/04)

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