306005845-3-27-2026-22-AS-EBEY-DSKNZX-20260327105504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005845
Report Date: 03/27/2026
Date Signed: 03/27/2026 10:55:22 AM

Document Has Been Signed on 03/27/2026 10:55 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 CARE		FACILITY NUMBER:	306005845
ADMINISTRATOR/ DIRECTOR:	LIMPIADO, GIDEON		FACILITY TYPE:	740
ADDRESS:	18676 SANTA MARIANA		TELEPHONE:	(949) 349-8708
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 5	DATE:	03/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Roel Atanacio - House Manager		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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	On March 27, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purposes of conducting a required 1-Year annual visit using the CARE Inspection Tool. LPA Bentley was greeted and granted entry by staff, after stating the reason for the visit. Administrator (AD) Julie Cornejo was out of town, contacted by telephone, and granted permission for staff to sign today’s inspection report. The facility is licensed to operate forage range 60 and over, for six (6) non-ambulatory elderly residents, of which one (1) may be Bedridden. The building is a single story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) staff bedrooms, three (3) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage. During the inspection, LPA Bentley toured inside and outside of the physical plant with staff. There were no bodies of water or obstructions on the premises. A comfortable temperature of 74 degrees F was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit and free of clutter and debris. 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 and available at the time of visit. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. Bathrooms were found to be clean and operational. The water temperatures in bathrooms measured at 129.0 degrees F to 130.4 degrees F. A deficiency is being cited. Continues on LIC 809-C….

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

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: SANTA MARIANA CARE	FACILITY NUMBER: 306005845
	VISIT DATE: 03/27/2026

NARRATIVE

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The facility last conducted an emergency safety drill on November 18, 2025. First aid kit is maintained and contains all the necessary elements The smoke alarms and carbon monoxide detectors were operable. A working telephone (714-916-0616) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were available. The facility has two (2) fire extinguishers that were charged, mounted, and serviced on March 11, 2026. Liability Insurance is effective July 20, 2025, and expires on July 20, 2026.

During the visit, LPA conducted an audit of five (5) resident files (R1-R5), five (5) staff files (S1-S5), and medication and medication administration records. A total of four (4) resident and three (3) staff were interviewed.

Based on observations, a deficiency was cited during the visit, per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, LIC809-D, Technical Violations, and Appeal Rights were provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2026 10:55 AM - It Cannot Be Edited

Created By: Eboni Bentley On 03/27/2026 at 10:42 AM

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: 03/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of three bathroom faucets, which poses an immediate healthy and safety risk to persons in care. LPA observed water temperatures between 129.0 and 130.4 degrees F in bathrooms used by residents in care.
	POC Due Date: 03/28/2026
	Plan of Correction
1 2 3 4	Licensee will test water temparures in two bathrooms, every two hours, over the next 24 hours and submit water temperature logs to CCLD by POC due date via eboni.bentley@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/27/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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