<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004588
Report Date: 07/15/2025
Date Signed: 07/15/2025 04:25:37 PM

Document Has Been Signed on 07/15/2025 04:25 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:CARING SISTERS HOME AND GARDEN @ LAKE FORESTFACILITY NUMBER:
306004588
ADMINISTRATOR/
DIRECTOR:		ESTHER CORTEZ REYFACILITY TYPE:
740
ADDRESS:23191 LA VACA STREETTELEPHONE:
(949) 613-1114
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
07/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Esther Rey AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 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 this day Licensing Program Analyst (LPA) William Vanegas conducted an unannounced visit for the purposes of completing an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Esther Rey. LPA Vanegas explained the purposes of the visit and began to set up equipment. LPA Vanegas began a tour of the facility and observed the following.

This is a two storied home with eight bedrooms, five of which are for resident use, and three bedrooms that are for live in staff on the second floor. LPA Vanegas observed the kitchen area to be clean and free of any mildew or debris. LPA Vanegas observed there to be an electric stove, dish washer, microwave, refrigerator, washer, and dryer. All appeared in good repair, and tested operational. LPA Vanegas observed a 2 day supply of perishable food, and a seven day supply of non-perishable food as well as a sufficient ammount of emergency water.

LPA Vanegas observed resident restrooms to be in clean and sanitary repair, LPA Vanegas observed restrooms to have operational water faucets, and toilets in good repair. Resident restrooms had all required furnishings such as a shower chair, grab bars, and slip resistant floor matts. Bathroom water tested between 114.3 and 114.5 degrees.

LPA Vanegas observed all resident rooms to have required furnishings such as a bed, clean linens in good repair; meaning no strains or tears, chest drawers, a reading lamp, and enough storage space to store personal belongings.
CONTINUED ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST
FACILITY NUMBER: 306004588
VISIT DATE: 07/15/2025
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
26
27
28
29
30
31
32
LPA Vanegas reviewed three resident files and one staff file. All files (resident and staff) had all required documents and staff annual training was complete. LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair, and tested operational. LPA Vanegas observed all fire extinguishers to be fully charged. LPA Vanegas observed an evacuation chair in the stairwell as well.

LPA Vanegas observed the outside of the facility to have a large backyard, large enough to participate in outdoor activities upon resident request. LPA Vanegas observed there to be an outdoor shaded sitting area, and no obstructions along the emergency exit route. Side doors are self latching and unlocked. LPA Vanegas observed first aid kit to have all required items such as adhesive tape, scissors, tweezers, bandages, a thermometer, and a first aid manual.

LPA Vanegas observed all hazards, toxins, and sharps to be locked away and inaccessible to residents in care. However LPA Vanegas observed centrally stored medications to not be locked. LPA Vanegas reviewed medications with AD Esther Rey, per LPA Vanegas review of medications all medications are being administered per physicians orders.

Based on today's observations a deficiency will be issued per tittle 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with AD Esther Rey, and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/15/2025 04:25 PM - It Cannot Be Edited


Created By: William Vanegas On 07/15/2025 at 04:17 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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST
FACILITY NUMBER: 306004588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as LPA Vanegas observed centerally stored medications not being locked durring facility tour which poses a potential health and safety risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
1
2
3
4
Administrator agrees to keep medication drawer locked, and conduct an updated training.
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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4