<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005726
Report Date: 05/20/2025
Date Signed: 05/20/2025 12:23:47 PM

Document Has Been Signed on 05/20/2025 12:23 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:TRADITIONS AT STACEY LEEFACILITY NUMBER:
306005726
ADMINISTRATOR/
DIRECTOR:		DE LOS REYES, LORDELEFACILITY TYPE:
740
ADDRESS:5105 EAST STACEY LEE LANETELEPHONE:
(714) 769-5858
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 6DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maricel Esguerra Care GiverTIME VISIT/
INSPECTION COMPLETED:
12:35 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 inspection for the purposes of conducting an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver Ernesto Esguerra, and explained the nature of the inspection. LPA Vanegas set up equipment and began a tour of the facility and observed the following.

This is a one storied home with six bedrooms; five of which are resident rooms, and one of which is a staff room. There are five bathrooms two of which are private bathrooms, and three of which are shared bathrooms. There is a two car attached garage as well. There is a large backyard, with a fully fenced pool with the fence measuring at 4ft 9in. The gaps between the fence rails are 5in apart, and the pool door swings away from the pool and not into it, and the pool gate is locked.

LPA Vanegas observed kitchen area to be clean and free of any mildew and debris. LPA Vanegas observed a refrigerator, electric stove, dishwasher, microwave, washer and dryer all to be in good repair and in working condition. LPA Vanegas observed a seven day supply of non perishable food and a two day supply of perishable food.

LPA Vanegas observed all resident bathrooms to be clean and free of any mildew and debris, water faucets and toilets tested operational. Bathrooms have all required furnishings such as a shower chair, grab bars, and slip resistant matts. Bathroom water temperature tested between 117.5 and 123.3 degrees.

CONTINUED ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
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: TRADITIONS AT STACEY LEE
FACILITY NUMBER: 306005726
VISIT DATE: 05/20/2025
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
26
27
28
29
30
31
32
LPA Vanegas observed the outside of the facility to have a large backyard, with a shaded sitting area, and a pool. Backyard is large enough to participate in outdoor activities upon resident request. LPA Vanegas observed the backyard to be clean and free of any obstructions along the exit routes of the facility.

LPA Vanegas observed all resident rooms to have the required furnishings such as a chest drawer, a bed, clean linens in good repair; meaning no strains or tears, a lamp, and enough storage space to store personal belongings. The rooms are large enough to walk about freely, and no obstructions are blocking entry ways.

LPA Vanegas observed all fire extinguishers to be fully charged, and up to date. LPA Vanegas observed 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, adhesive tape, scissors, tweezers, and a thermometer.

LPA Vanegas reviewed two staff files, and six resident files. One of two staff files contained all documents however one was missing pertinent information. All resident files were missing required documents and a deficiency was issued. LPA Vanegas reviewed medication administration log, and observed all medication to be documented correctly and administered to residents in care per physicians orders.

Based on today's observations during the inspection deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was completed with Administrator Lordele De Los Reyes 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: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/20/2025 12:23 PM - It Cannot Be Edited


Created By: William Vanegas On 05/20/2025 at 12:04 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: TRADITIONS AT STACEY LEE
FACILITY NUMBER: 306005726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of two staff members not having completed required 40 hours of annual training. Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
1
2
3
4
Administrator will conduct training with employee, and obtain their 1st aid and CPR certification. Administrator will submit proof of correction to LPA by P.O.C due date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in six out of six resident files not having required documents in their files which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
1
2
3
4
Administrator will obtain all required documents for residents in care, and send proof of correction to LPA by POC 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5