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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005782
Report Date: 03/16/2026
Date Signed: 03/16/2026 01:07:08 PM

Document Has Been Signed on 03/16/2026 01:07 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:RESPIT MANOR MISSION VIEJOFACILITY NUMBER:
306005782
ADMINISTRATOR/
DIRECTOR:		MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23412 VIA GUADIXTELEPHONE:
(949) 331-7578
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
03/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mark MendezTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On March 16, 2026, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted the facility administrator (AD) Mark Mendez about the visit. For this visit, there are two staff members on duty, both of which are background cleared and associated. AD later arrived to assist with the inspection.

The PUB475 ‘See Something, Say Something’ poster was observed to be located near the front entrance. LPA observed that Mark Mendez has a valid Administrator certificate which expires on September 26, 2026.

The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, six of which may be non-ambulatory, one of which may be bedridden, and a hospice waiver for six. LPA toured the interior and exterior portions of the facility with AD. For this visit, there are a total of two non-ambulatory residents, and one ambulatory resident in care, no one is on hospice, and none are bedridden.

The facility is a single story home. There are a total of four bedrooms, two of which are private resident bedrooms and two shared bedrooms. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and free of any hazards. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of two bathrooms.

Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathroom were measured to be 121.8 degrees Fahrenheit. Continued on LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2026
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 6
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 03/16/2026 01:07 PM - It Cannot Be Edited


Created By: Garlli Tat On 03/16/2026 at 12:06 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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the medication Furosemide 20mg tablet for Resident #3 has an extra pill in the bubblepack, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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The Licensee will train all caregivers and provide proof to CCLD by Plan of Correction due date via email or fax.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not have an updated Appraisal/Needs and Services plan for three out of three residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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The Licensee will obtain updated Appraisal/Needs and Services plans for all residents in care and provide proof to CCLD via email by Plan of Correction 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/16/2026 01:07 PM - It Cannot Be Edited


Created By: Garlli Tat On 03/16/2026 at 12:06 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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 have a quarterly emergency drill this year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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The Licensee will ensure all staff have an emergency drill this quarter and document the date, time, all employees involved, and provide a signed copy to CCLD by the Plan of Correction due date.
Type B
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the fire extinguisher was purchased on July 1, 2024 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
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The Licensee will purchase a new fire extinguisher or have current fire extinguisher tagged for this year and provide proof to CCLD by Plan of Correction 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
VISIT DATE: 03/16/2026
NARRATIVE
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked in the kitchen and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. Fire extinguisher was purchased on July 1, 2024. LPA observed the emergency disaster and evacuation plan, which is posted in the dining room. Facilitator stated the facility conducted their last emergency disaster drill last year, but it was not documented. Facility had back-up emergency food and water supply, located in the garage. LPA observed that the First Aid kit had all the required components. Medications were observed to be locked in a medication cabinet in the dining room, inaccessible to residents in care. Chemicals were observed to be locked in the garage. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage and laundry.

For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards or obstructions. There are two self-latching gates in the backyard that can be opened in case of an emergency. No bodies of water were observed.

During this visit, three resident files and two staff files were reviewed. All staff are background cleared and associated with the facility. LPA reviewed residents’ medication and medication records and two resident and two staff interviews were conducted.

Based on today's observations, there are deficiencies being cited per Title 22 of the California Code of Regulations. Technical violations were issued.

An exit interview was conducted with Mark Mendez. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Rights were reviewed.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
LIC809 (FAS) - (06/04)
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