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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005845
Report Date: 02/04/2025
Date Signed: 03/14/2025 11:29:04 AM

Document Has Been Signed on 03/14/2025 11:29 AM - 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:SANTA MARIANA CAREFACILITY NUMBER:
306005845
ADMINISTRATOR/
DIRECTOR:		LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:18676 SANTA MARIANATELEPHONE:
(949) 349-8708
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Julie Way Cornejo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On February 4, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a required one-year annual visit using the CARE Inspection Tool. LPA Bentley was greeted and granted entry by Caregiver (CG) Roel Atanacio, and explained the reason for the visit. Administrator (AD) Julie Way Conejo arrived a short time later and was present for today’s visit. AD Cornejo has an Administrator Certificate with an expiration date of June 3, 2026.

This facility is a one-story building in a residential neighborhood, licensed to provide services to age range 60 and over, approved for six (6) Non-Ambulatory residents of which one (1) may be bedridden and has a hospice waiver for four (4) residents. Currently, there are five (5) residents on census of which two (2) are receiving hospice care. All five (5) residents were present during today’s visit.

Around 9:00AM, LPA Bentley conducted a tour of the physical plant accompanied by AD Cornejo and the following was observed: All resident bedrooms and bathrooms were inspected. Each bedroom had adequate lighting, furniture, bedding, and storage for the residents’ personal belongings. Additional bed linens, comforters, and bath towels were available during the visit. Hot water temperatures in bathrooms were measured and observed between 105.2 degrees and 113.3 degrees Fahrenheit.

The kitchen was clean and organized. All knives and sharp objects were kept locked in a drawer below the counter. A supply of perishable food items was observed in the refrigerator and nonperishable food items observed in the cabinets.

The garage was partially used for storage and all walkways free of clutter. There was a refrigerator with a supply of perishable items inside. LPA Bentley also observed a washer and dryer, additional boxes of supplies, and emergency food and water.
CONTINUE TO 809-C PAGE....
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/14/2025 11:29 AM - It Cannot Be Edited


Created By: Eboni Bentley On 02/04/2025 at 04:34 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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

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 observation, the licensee did not comply with the section cited above in four out of four stove burners, which poses a potential health and safety risk to residents in care. During this visit, LPA observed all burners on the stovetop were not operational and a lighter was being used to start the burners.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee agrees to discontinue use of lighter to ignite inoperable burners immediately. Licensee will repair or replace the burners on the stovetop and submit proof of correction to LPA via CCLD email to eboni.bentley@dss.ca.gov by POC due date.
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
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care. LPA observed three out of four personnel files missing annual staff training on postural supports, restricted health conditions, demntia, and hospice care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee agrees to conduct training with all three out of four staff and will submit proof of correction to LPA via CCLD email to eboni.bentley@dss.ca.gov 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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


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Document Has Been Signed on 03/14/2025 11:29 AM - It Cannot Be Edited


Created By: Eboni Bentley On 02/04/2025 at 04:34 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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review and interview, the licensee did not comply with the section cited above, which poses a potential health, safety and personal rights risk to persons in care. Based on record review, LPA observed that Resident #1, Resident #2, Resident #3, and Resident #4 do not have Initial and Annual Appraisals/Needs and Services plans.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee agrees to complete updated Appraisal/Needs and Service Plans for Resident #1, Resident #2, Resident #3, and Resident #4 and will submit proof of correction to LPA via CCLD email to eboni.bentley@dss.ca.gov by 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.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


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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: SANTA MARIANA CARE
FACILITY NUMBER: 306005845
VISIT DATE: 02/04/2025
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The backyard was clean and free of clutter and debris. There is one (1) side exit gate, clear and accessible and a shaded patio area with tables and seating observed. There are no bodies of water.

A review of five (5) residents (R1-R5) service files and four (4) staff (S1-S4) personnel files was conducted. Three (3) residents and two (2) staff interviews were reviewed. A review of the Medication Records Administration (MAR) and medication was conducted, and records were found to be in compliance.

The facility has liability insurance effective July 20, 2024 through July 20, 2025. A first aid kit was observed with all the required elements present. There are two (2) fully charged fire extinguishers, observed mounted with a last service date of March 19, 2024. Smoke detectors were tested and operational and the last fire and disaster drill was conducted on January 6, 2025.

Three (3) deficiencies and two (2) Technical Violations were cited during today’s inspection visit.

An exit interview conducted and a copy of the report was provided to Administrator Julie Way Cornejo.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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