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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005254
Report Date: 06/02/2025
Date Signed: 06/02/2025 01:36:04 PM

Document Has Been Signed on 06/02/2025 01:36 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:EMY'S PLACE OF MISSION VIEJOFACILITY NUMBER:
306005254
ADMINISTRATOR/
DIRECTOR:		PINERA, DOMINADOR C JRFACILITY TYPE:
740
ADDRESS:24176 CARRILLO DRIVETELEPHONE:
(949) 273-5987
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
06/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Emy Pinera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility administrator Emiliana Pinera after stating the purpose of the visit.

There are currently three residents in care, none of which are receiving hospice care at this time. LPA observed residents relaxing in the facility's common living areas or in their respective bedrooms. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has four bedrooms along with one locked staff room along with two shared bathrooms and one en-suite bathroom off of a shared room which currently only houses one occupant.

Bedrooms appear clean and sanitary. Two residents are observed using half-rails postural supports at the time of the visit, consultation provided and licensee instructed to submit adequate physician orders at the earliest convenience. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 111F in two separate bathrooms equipped with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secured.

The wall-mounted fire extinguisher is charged with up-to-date maintenance. Smoke and carbon monoxide detectors were found to be operational. The garage is inaccessible to residents and used for laundry as well as additional storage of supplies. CONTINUED ON FORM LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2025
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: EMY'S PLACE OF MISSION VIEJO
FACILITY NUMBER: 306005254
VISIT DATE: 06/02/2025
NARRATIVE
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CONTINUED FROM LIC809
LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. There are two self-latching gates on each side of the property. One gate was damaged off its hinge during a facility renovation and is scheduled for repairs. The identified route of egress is however free of clutter and obstructions. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress.

LPA reviewed three resident records which included all necessary components. Consultation provided on regular physician assessments. One resident self-administers their own weekly Ozempic injection and is able to self-administer per staff assessment. Their physician report however needs to be updated as soon as possible as the assessment does not corroborate the resident's current condition. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Oxygen is currently in use on the premises with adequate signs observed. There are no residents currently assessed as being bedridden at the time of the visit. Resident interviews were conducted or attempted during the visit along with staff interviews.

LPA reviewed staff records for two staff members present during the visit. Present staff member has a current CPR certificates on file, however administrator Emiliana Pinera also provides care and covers the overnight shift. CPR training for Mrs. Pinera has lapsed. Type B citation issued. Annual training on file, consultation provided on the need to document dates for annual and initial staff training. Disaster drills are conducted however they are not held quarterly nor documented. Type B citation issued. Both staff members present are background cleared and associated to the licensed location.

Based on the observations made during today’s visit, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2025 01:36 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 06/02/2025 at 01:04 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: EMY'S PLACE OF MISSION VIEJO
FACILITY NUMBER: 306005254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as both the licensee and administrator appear to have a lapsed CPR certificate as of January 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee will update their CPR training and provide proof of completion before the plan of corrections due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in as there were only two drills conducted in 2024 and no drills have yet to be documented for 2025. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee will schedule one drilll for every quarter and document attendance as described above. Proof of completion to be provided to LPA before the plan of corrections 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2025


LIC809 (FAS) - (06/04)
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