306005283-9-15-2025-22-AS-RMAZ-DLJUE6-20250915153036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005283
Report Date: 09/15/2025
Date Signed: 09/15/2025 03:30:44 PM

Document Has Been Signed on 09/15/2025 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:	ORANGE GROVE		FACILITY NUMBER:	306005283
ADMINISTRATOR/ DIRECTOR:	GOLDSTEIN, ERIC		FACILITY TYPE:	740
ADDRESS:	22182 ADAMO STREET		TELEPHONE:	(949) 279-1700
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6		CENSUS: 4	DATE:	09/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Sherry Dizon		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Ruth Martinez arrived to the facility to conduct a year required inspection. Upon arrival LPA was greeted at the door by caregiver and granted entry. LPA met with Sherry Dizon, Administrator, and explained the nature of the visit. LPA was informed that there are four (4) clients currently reside at facility and one (1) resident is receiving hospice services. LPA began a tour of the kitchen and food storage areas. Food supply adequately meets requirements for a two day supply of perishables and a seven day supply of non-perishable foods on hand. Fresh fruits and vegetables are readily available for residents. LPA observed a locked area for sharps and one for cleaning supplies. No health and safety concerns observed. LPA toured all of the bedroom areas. The facility has six bedrooms designated for residents and two employee bedrooms. Smoke detectors were observed in all areas of the house and testing the device proved that it is operational. LPA observed in residents’ bedrooms that all the required furnishings were present, and that lighting was sufficient for comfort and safety. Beds were made meeting all the requirements for linens. Furniture and fixtures were in good repair and meet regulatory requirements. An adequate amount of closet and storage space designated for personal belongings/clothing is available for each client. LPA observed a fire extinguisher last inspection date of April 15, 2025. LPA verified last Fire Drill are conducted quarterly and the last drill was conducted on July 15, 2025. LPA toured restrooms designated for residents. LPA tested the water, and the water temperature measured 114.4 Fahrenheit degrees. Shower safety equipment is present. An adequate number of towels are available for residents use. LPA checked the outside perimeter of the facility. LPA observed that the latching mechanisms on the fences allow access in case of emergency. All passage ways are clear and free Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

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: ORANGE GROVE	FACILITY NUMBER: 306005283
	VISIT DATE: 09/15/2025

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of obstruction. The facility has a shaded area for outside use. LPA began reviewing records. LPA reviewed two resident records. All the required documentation was present and current in files reviewed. LPA reviews two employee records. All employees present have a criminal record clearance and are associated with this location. LPA as a reminder provided annual fee dues information.

Based on the observations made during this visit there are no deficiencies being cited per Title 22, Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was being provided and left at facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC809 (FAS) - (06/04)

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