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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005647
Report Date: 10/31/2024
Date Signed: 10/31/2024 02:49:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/31/2024 02:49 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 SUN SENIOR CAREFACILITY NUMBER:
306005647
ADMINISTRATOR/
DIRECTOR:		DADABHOY, MUQEETFACILITY TYPE:
740
ADDRESS:24532 SPARTAN STREETTELEPHONE:
(949) 600-5346
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Christopher Martinez- CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Jessica Cho and Ebony Bentley arrived unannounced for the purpose of conducting the Required 1 Year Inspection. LPAs observed trash and debris in a trailer parked in the driveway. LPAs observed a sign indicating facility closure due to a water leak. LPA Cho contacted Administrator (Admin) Muqeet Dadabhoy by telephone at 12:37pm and stated the purpose of the visit. Admin stated that the water leak occurred from the kitchen approximately April 2024. There were two residents residing at the time of the leak. Two residents had agreed to relocate and was placed at another facility operated by the administrator. Admin stated that he is not accepting any residents until the renovation is complete. Admin acknowledged that the Department was not notified of the leak and the alterations made inside the facility. Approximately 12:56pm, Caregiver Christopher Martinez arrived to the facility on behalf of Admin to assist LPAs with the annual inspection. LPAs conducted a tour of the facility and observed there were no residents/staff on site. LPAs observed part of the floors replaced, installation of a small bathroom which used to be a closet, renovated one large bathroom as well as expanding a bathroom and eliminating a closet in Room #6, and renovating the backyard landscape. Facility is not accepting residents at this time.
The annual licensing fee remains current with a balance of $0.

Admin was advised on the following: to submit a written report of any major occurrences which threatens the health, safety, and welfare of residents within 24 hours, to notify the Department when renovations or alterations being made to the facility and upon completion and prior to admitting a new resident.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC9099Ds.

Administrator Dadabhoy verbally authorized Caregiver Martinez to sign the report on his behalf. An exit interview was conducted with Caregiver Christopher Martinez, and a copy of this report, along with the LIC9099s, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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Document Has Been Signed on 10/31/2024 02:49 PM - It Cannot Be Edited


Created By: Jessica Cho On 10/31/2024 at 01:54 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: PACIFIC SUN SENIOR CARE
FACILITY NUMBER: 306005647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
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Adminstrator stated that they will submit a letter of intent, LIC200, copy of the original and the new facility sketches indicating the changes, and submiting a check in the amount of $25.00 payable to (and spelled out) California Department of Social Services.
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Based on observation and interviews, the licensee did not comply with the section cited above in which the facility did not maintain an approved fire clearance for the installation of a new bathroom as well as the expansion of the resident's bathroom eliminating the closet which poses an immediate health, safety, or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


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Document Has Been Signed on 10/31/2024 02:49 PM - It Cannot Be Edited


Created By: Jessica Cho On 10/31/2024 at 02:18 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: PACIFIC SUN SENIOR CARE
FACILITY NUMBER: 306005647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2024
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...: (2) Occurrences, such as..., catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours...to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by:
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Adminstrator stated that a written incident report of the water leak and an Acknowlegement of Understanding of the said deficiency will be submitted to LPA via email by POC due date.
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Based on observations and interviews, the Department was not notified of the water leak and renovation which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
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