306004629-6-18-2025-22-AS-WVAS-DHRUDU-20250618153007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004629
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:30:18 PM

Document Has Been Signed on 06/18/2025 03:30 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:	PACIFIC SHORES OF LAGUNA HILLS		FACILITY NUMBER:	306004629
ADMINISTRATOR/ DIRECTOR:	BENIGNO BULANADI		FACILITY TYPE:	740
ADDRESS:	24961 SOUTHPORT STREET		TELEPHONE:	(949) 683-8736
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6		CENSUS: 5	DATE:	06/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Herminia "Amy" Zuhel Administrator		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	Licensing Program Analyst (LPA) William Vanegas conducted an unannounced visit for the purposes of conducting an annual inspection. Upon arrive LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Dorlie Gasco. LPA Vanegas explained the purpose for the visit and began a tour of the facility and observed the following. This is a two storied facility with seven bedrooms, two of which are used for staff, and five of which are used for residents. There are three bathrooms, and a two car attached garage, and a large backyard. LPA Vanegas observed the kitchen area to be clean and free of any debris or mildew. LPA Vanegas observed there to be a two day supply of perishable food, and a seven day supply of non-perishable food. LPA Vanegas observed there to be a gas stove, microwave, dishwasher, refrigerator, washer and dryer all to be in good repair and tested operational. LPA Vanegas observed all resident restrooms to be clean and free of any mildew and debris. LPA Vanegas observed toilets and faucets to be operational. LPA observed restrooms to have all required furnishings such as grab bars, slip resistant floor matts, and shower chair. Bathroom water tested between 105.9 and 106.8 degrees. LPA Vanegas observed all resident bedrooms to have all required furnishings such as a bed, chest drawer, lamp, clean linens in good repair; meaning no strains or tares, and enough storage space to store personal belongings. LPA observed there to be no obstructions blocking entry way to the residents rooms. CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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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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: PACIFIC SHORES OF LAGUNA HILLS	FACILITY NUMBER: 306004629
	VISIT DATE: 06/18/2025

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LPA Vanegas observed all fire extinguishers to be up to date and fully charged, and all smoke and carbon monoxide detectors to be in good repair, and operational. LPA Vanegas observed first aid kit to have all required items such as bandages, first aid manual, tweezers, scissors, and a thermometer.

LPA Vanegas toured the outside of the facility and observed there to be a large backyard with a shaded sitting area, there are no obstructions blocking the exit routes, and the backyard is clean and in good repair. The backyard is large enough to participate in outdoor activities upon resident request.

LPA Vanegas reviewed five resident files and two staff files. All files (resident and staff) had all required documents and staff annual training was up to date, and documented correctly. LPA Vanegas reviewed medications with AD Herminia "Amy" Zuhel and observed medications to be documented correctly and per LPA Vanegas review medications are being administered per physicians orders.

Based on observations made during today's inspection no deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with AD Herminia "Amy" Zuhel 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: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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