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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003937
Report Date: 06/06/2025
Date Signed: 06/20/2025 05:12:36 PM

Document Has Been Signed on 06/20/2025 05:12 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:LOS TIEMPOS SENIOR LIVINGFACILITY NUMBER:
306003937
ADMINISTRATOR/
DIRECTOR:		ROSA FIGUEROAFACILITY TYPE:
740
ADDRESS:17935 LOS TIEMPOS STREETTELEPHONE:
(714) 964-6310
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator - Rosa “Janeth” Figueroa TIME VISIT/
INSPECTION COMPLETED:
10:30 PM
NARRATIVE
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On June 6, 2025 at 10:15am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility to conduct an unannounced required 1-Year annual visit using the CARE Inspection Tool. LPA announced self and stated the purpose of the visit to Caregiver (CG) Francis Fonseca and was granted entry. Administrator (AD) Rosa “Janeth” Figueroa was contacted by telephone, arrived at the facility a short time later, and was present throughout the inspection. Administrator certificate for Rosa Figueroa expires on September 8, 2025.

There are six residents on census. One resident on Hospice and three with dementia currently living at the facility. During today’s visit, six residents and three staff are present. LPA obtained copies of pertinent documents for clients and staff, including facility records: resident/staff rosters, Personnel Record (LIC500), resident and staff records.

The facility is a one story home licensed for 6 non-ambulatory residents and has a Hospice waiver for 4. There are 5 resident bedrooms, 4 bathrooms, a living room area, a kitchen, a dining room area, and attached two car garage.

Around 11:00am, LPA conducted a tour of the facility with AD Figueroa and the following was observed:
Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperatures measured between 101.3 degrees F. and 102.5 degrees F and a deficiency was cited. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit.
CONTINUE TO LIC 809-C PAGE
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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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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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Document Has Been Signed on 06/20/2025 05:12 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/06/2025 at 08:14 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: LOS TIEMPOS SENIOR LIVING
FACILITY NUMBER: 306003937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not have health screening records for three out of five personnel staff. LPA observed Staff #1, Staff #2, and Staff #3 did not have health screening record.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee stated she will have a doctor come to the facility to assess staff and compete Health Screening Record for those that do not have one by POC due date. Licensee will send proof to CCLD via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2025 05:12 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/06/2025 at 08:17 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: LOS TIEMPOS SENIOR LIVING
FACILITY NUMBER: 306003937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in five out of six resident beds, which poses an immediate health and safety risk to persons in care. LPA observed six resident beds and five with bed rails attached. Licensee stated they did not have all six orders. Only one order.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee agrees to obtain an order from residents physician's for all bedrail by POC due date. Bedrail orders to be emailed to CCL to verify POC completion.
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, hot water temperatures in four out of four restroom faucets measured between 101.3 degrees F and 102.5 degree F., which poses an immediate health and safety risk to residents in care. LPA Observed hot water temperatures in Bathroom #1, Bathroom #2, Bathroom #3, and Bathroom #4 measured below 105 degrees F.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee stated they will submit water temperature logs for all four restrooms by end of POC due date. Licensee will send proof to CCLD via email. LPA observed Licensee adjust hot water during visit.
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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2025 05:12 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/06/2025 at 08:24 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: LOS TIEMPOS SENIOR LIVING
FACILITY NUMBER: 306003937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(l)
(l) Residents receiving hospice care or prospective residents already receiving hospice care when accepted as residents who are bedridden, may reside in the facility provided the facility meets the requirements of Section 87606, Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of six residents in care, which poses an immediate health and safety risk to persons in care. LPA observed Physician's report for resident Resident #1 stating resident is bedridden. Facility does not currently have a fire clearance for bedridden residents.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee stated they will submit a written plan with LIC 200 application immediately requesting new fire clearance for Bedridden resident and submit proof to CCLD by POC due date.
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in five out of five resident bedrooms, which poses an immediate health and safety risk to persons in care. LPA observed non operational fire alarms in five resident bedrooms. Licensee contacted vendor and scheduled replacements during visit.
POC Due Date: 06/07/2025
Plan of Correction
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Licensee stated they will purchase new alarms and install in all rooms immediately. Licesee will submit proof to CCLD by POC due date.
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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


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: LOS TIEMPOS SENIOR LIVING
FACILITY NUMBER: 306003937
VISIT DATE: 06/06/2025
NARRATIVE
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Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen was inspected and found clean and sanitary. Perishable and non-perishable food supply were checked and adequately stocked at time of visit. LPA observed knives and sharps locked in a kitchen cabinet. LPA also observed toxin substances to be secured, locked and inaccessible to residents in the garage. Kitchen appliances were operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gate is self-latching and operational.

A carbon monoxide/smoke detector in the main hallway was tested and operational. Smoke detectors in five bedrooms were found non-operational and a deficiency was cited. The facility’s last fire drill was conducted on April 30, 2025. Emergency food and water supply observed in the garage. First aid kit had all the required elements. Three fire extinguishers are fully charged with a service date of June 4, 2024 and licensee confirmed vendor will service on June 9, 2025. A working telephone (714-964-6310) remains available, and the facility has a device that can be used for video teleconference purposes. Liability Insurance is effective June 26, 2024, through June 6, 2025 and licensee confirmed policy will be corrected to cover June 26, 2024, through June 26, 2025

LPA Bentley conducted an audit of five (5) resident files (R1-R5), five (5) staff files (S1-S5), and conducted three (3) staff interviews, and four (4) resident interviews. Residents’ medication was found locked, and a review of the Medication and Medication Administration Record (MAR) was conducted.

Based on today’s observations, deficiencies are being cited and two civil penalties issued during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with administrator, Rosa Janeth Figueroa and a copy of this report LIC809, 809-C, LIC809-D, CP421 and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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