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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005762
Report Date: 05/19/2025
Date Signed: 05/19/2025 04:13:24 PM

Document Has Been Signed on 05/19/2025 04:13 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:RELIANCE SENIOR HOMEFACILITY NUMBER:
306005762
ADMINISTRATOR/
DIRECTOR:		SANSANO, MINERVAFACILITY TYPE:
740
ADDRESS:24672 ELOISA DRTELEPHONE:
(949) 295-6854
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
05/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Ray SantianezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On May 19, 2025, at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Helen Carcino. Administrator (AD) Ray Santianez arrived at the facility a short time later and was present during the remainder of the visit. AD Ray Santianez has an administrator certificate with an expiration date of August 18, 2025.

The facility is a single level structure, licensed for six (6) non-ambulatory residents of which one (1) may be bedridden and has a hospice waiver for six (6) residents. The home consists of the following: six (6) resident bedrooms, one (1) staff rest area, two (2) bathrooms, living room area, dining area, kitchen, outdoor shaded seating areas, and an attached two car garage.

During the visit, LPA Bentley obtained the facility's resident and staff rosters and LIC 500 Personnel Record. LPA toured the interior and exterior of the physical plant with AD Santianez and the following was observed:. All mandated posters were posted near the entrance. There were 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. Bathrooms were found to be clean and operational. The water temperatures measured at 111.0 degrees F to 113.9 degrees F. A comfortable temperature of 73 degrees F was maintained throughout the facility.


CONTINUE TO LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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)
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Document Has Been Signed on 05/19/2025 04:13 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/19/2025 at 01:21 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: RELIANCE SENIOR HOME
FACILITY NUMBER: 306005762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview, the licensee did not comply with the section cited above in one out of four stove burners which posed a potential health and safety risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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Licensee stated they will repair non-operational stove top burners and provide proof to the department and LPA via email by POC date. Licensee had vendor assess the repair during the visit and provide receipt of visit. Licensee stated vendor will order part and repair burner before POC due date.
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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/19/2025 04:13 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/19/2025 at 01:21 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: RELIANCE SENIOR HOME
FACILITY NUMBER: 306005762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

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 six out of six resident's needs and services plans, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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Licensee stated they will meet with six out of six resident representatives to review needs and services plans. Licensee will provide proof, with signatures to the department and LPA via email by POC 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 4 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: RELIANCE SENIOR HOME
FACILITY NUMBER: 306005762
VISIT DATE: 05/19/2025
NARRATIVE
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LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharps objects were stored and locked. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available.
There is a two car garage with a refrigerator and additional supply of perishable items. The washer and dryer were observed to be in working condition. Facility has a sufficient amount of emergency food supply and water supply. The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs was observed.

Emergency safety drill was last conducted on April 10, 2025 and conducted quarterly. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were tested and observed operational. A working telephone (949-446-4475) remains available, and the facility has a device that can be used for video teleconference purposes. The facility has three (3) fire extinguisher that were observed charged in the kitchen, laundry room and garage, all last serviced on April 16, 2025. Liability Insurance is effective June 14, 2024 through June 14, 2025.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), two (2) staff interviews, and five (5) resident interviews. Clients’ medication was found locked and secure and a review of the Medication and Medication Administration Record (MAR) was conducted.

Based on today’s observations, two Type B deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, deficiency pages, and appeal rights were provided to Administrator Ray Santianez.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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