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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005322
Report Date: 07/25/2025
Date Signed: 07/25/2025 04:07:41 PM

Document Has Been Signed on 07/25/2025 04:07 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:ACTIVCARE AT YORBA LINDAFACILITY NUMBER:
306005322
ADMINISTRATOR/
DIRECTOR:		ENRIQUE LEDESMAFACILITY TYPE:
740
ADDRESS:4725 VALLEY VIEW AVETELEPHONE:
(714) 577-8005
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 80CENSUS: 54DATE:
07/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Executive Director- Enrique LedesmaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On July 25, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Enrique Ledesma and explained the purpose of the visit.

The facility is licensed to operate for eighty (80) non-ambulatory, of which seventeen (17) may be bedridden, and have a hospice waiver for fifteen (15) residents. Facility is approved for delayed egress and secure perimeter, and a waiver for locked perimeter gates. The facility is a single-story structure, which consists of the following: fifty-four (54) resident bedrooms, six (6) office rooms, thirty-eight (38) bathrooms, waiting area, activity area, dining room, kitchen, and two (2) outdoor covered patio areas.

LPA Kim toured indoor and outdoor of the physical plant with ED Ledesma. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 102, Resident Room 203, Resident Room 206, Resident Room 207, Resident Room 208, Resident Room 302, Resident Room 305, Resident Room 402 and Resident Room 406. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 110.4 degrees F and 117.5 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2025
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: ACTIVCARE AT YORBA LINDA
FACILITY NUMBER: 306005322
VISIT DATE: 07/25/2025
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food is stored in the kitchen. Emergency water and emergency supplies were stored in a storage closet. A working telephone (714-577-8005) remains available and is dedicated to the residents. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on June 15, 2025. The facility has eleven (11) fire extinguishers that were charged and they were all serviced on September 5, 2024. All smoke detectors and carbon monoxide detectors were operable and last checked on October 29, 2024, by Orange County Fire Authority. First Aid was maintained and contained all the necessary elements. Certificate of Liability insurance is effective October 10, 2024, and expires on October 10, 2025.

LPA Kim conducted an audit of eight (8) resident files (R1-R8), eight (8) staff files (S1-S8), and medication and medication administration record. LPA observed R1’s medical assessment dated June 25, 2024, and was diagnosed with dementia. LPA also observed S1, S2, and S3 did not complete twenty hours of training for 2024. LPA conducted six (6) resident interviews and four (4) staff interviews.

A deficiency was cited during the visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). The annual twenty hours of staff training for three out of eight staff (S1, S2, and S3), were not completed. A technical violation was assessed during the visit. LPA observed R1, diagnosed with dementia, did not have a current medical assessment for 2025. The last medical assessment was dated June 25, 2024.

An exit interview was conducted, and a copy of this report, LIC811, LIC809D, and appeal rights were provided to Executive Director Enrique Ledesma.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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


Created By: Edward Kim On 07/25/2025 at 03:40 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: ACTIVCARE AT YORBA LINDA
FACILITY NUMBER: 306005322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of eight staff. LPA observed S1, S2, and S3 did not complete the 20 hours for 2024, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee states they will read and sign a statement of understanding for Health Safety Code 1569.625(b) and will send a plan that will ensure staff complete the 20 hours for 2025. Licensee will send proof of this to CCLD via email to edward.kim@dss.ca.gov by POC due date August 8, 2025.
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:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2025


LIC809 (FAS) - (06/04)
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