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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005755
Report Date: 06/06/2025
Date Signed: 06/06/2025 04:37:37 PM

Document Has Been Signed on 06/06/2025 04:37 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:SACRED HEART SENIOR CAREFACILITY NUMBER:
306005755
ADMINISTRATOR/
DIRECTOR:		ALDIANO, ANNA LIZAFACILITY TYPE:
740
ADDRESS:25602 WILLOW BENDTELEPHONE:
(949) 600-7009
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Facility Administrator - Marebith NeryTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez was greeted and granted entry by facility administrator (AD) Marebith Nery. For this visit, there are a total of 6 residents in care, of which 2 are on hospice.

LPA Rodriguez observed the administrator certificate for Marebith Nery which expires on July 22, 2025. LPA Rodriguez observed that the PUB475 "See Something, Say Something" poster was posted in the hallway of the facility.

The facility has a total of 6 bedrooms, of which all private resident rooms. LPA Rodriguez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Facility was observed to have 3 bathrooms, of which were observed to be in good repair, and toilets were operational. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational.

Hot water was measured at 113.6 degrees Fahrenheit. LPA Rodriguez observed that the facility had a two-day supply of perishables and a seven-day supply of non-perishable food. LPA Rodriguez observed hallways were free of obstructions.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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: SACRED HEART SENIOR CARE
FACILITY NUMBER: 306005755
VISIT DATE: 06/06/2025
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For the exterior portion, LPA Rodriguez observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

LPA Rodriguez observed that the facility has fire extinguishers that were charged, mounted and located in the throughout the facility with maintenance tags dated for July 2024. Sharp items, and medications were observed to be in a locked cabinet located in the kitchen. Cleaning supplies were observed to be locked and inaccessible to residents in care. LPA Rodriguez observed that the facility has the Emergency Disaster and Evacuation plan located in the facility binder, and emergency supplies located in the garage and in a pantry.

LPA Rodriguez reviewed all six resident files. LPA Rodriguez reviewed staff files, and observed that present staff members are cleared and associated to the facility.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Nery.

A copy of this report and Appeal Rights were explained and provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 06/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/06/2025 04:37 PM - It Cannot Be Edited


Created By: Celine Rodriguez On 06/06/2025 at 03:28 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: SACRED HEART SENIOR CARE
FACILITY NUMBER: 306005755

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
87463 Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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. 1 out of the 6 residents present did not have an updated physician report as of November 2023. Facility administrator verified that the resident's most recent physician report is dated for 2023. This poses a potential health, and safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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As a plan of correction, facility is to obtain an updated physician report for resident. Facility is to submit proof to assigned LPA on or by 6/20/2024.
Type B
Section Cited
CCR
87555(b)(8)
87555 General Food Service Requirements

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. During the visit, LPA observed cans of expired food dated for April 2025. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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As a plan of correction, facility is to discard the expired food. Facility is to submit proof to the assigned LPA on or by 6/6/2025.
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:
Celine Rodriguez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2025


LIC809 (FAS) - (06/04)
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