306005865-2-5-2026-22-AS-WVAS-DR22VW-20260205164438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005865
Report Date: 02/05/2026
Date Signed: 02/05/2026 04:45:27 PM

Document Has Been Signed on 02/05/2026 04:45 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		FACILITY NUMBER:	306005865
ADMINISTRATOR/ DIRECTOR:	MENDEZ, MARK		FACILITY TYPE:	740
ADDRESS:	23255 RESPIT AVE		TELEPHONE:	(949) 460-0317
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 5	DATE:	02/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Mark Mendez (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

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	Licensing Program Analyst (LPA) made an unannounced visit for the purposes of conducting an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by facility staff. LPA explained the purpose of the visit. Administrator (AD) Mark Mendez was notified via telephone, and arrived shortly after to assist with the annual inspection. LPA Vanegas observed AD has a valid Administrator certificate. LPA began a tour of the facility and observed the following. The facility is a one storied home with five bedrooms that are all utilized by residents in care. three bathrooms utilized by residents in care, staff, and visitors, and an attached two car garage. LPA observed kitchen to be clean and free any mildew and debris. LPA observed a two day supply on non-perishable food, and a seven day supply of non-perishable food on hand. LPA observed a dishwasher, microwave, gas stove, refrigerator, washer, and dryer to be in good condition and operational. LPA Vanegas observed all fire extinguishers to be up to date and fully charged. LPA observed all smoke detectors and carbon monoxide detectors to be in good condition and operational. LPA observed all resident rooms to be clean, and free of any hazards. LPA Observed all rooms to have required furnishings such as a bed, chest drawers. a reading lamp, and enough storage space to store personal belongings. LPA observed facility bathrooms to have operational water faucets, and toilets. Bathrooms had required furnishings such as grab bars, a shower chair, and slip resistant floor matts. Hot water temperature tested between 112.2 and 114.3 degrees. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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: RESPIT MANOR	FACILITY NUMBER: 306005865
	VISIT DATE: 02/05/2026

NARRATIVE

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LPA observed the outside of the facility to be clean and free of any hazards. LPA observed side doors to be self latching and unlocked. LPA Observed there to be an outdoor shaded sitting area, and enough space to participate in outdoor activities upon resident request. LPA observed all smoke detectors and carbon monoxide detectors to be in good condition and operational. LPA observed fire extinguishers to be fully charged and recently purchased with a receipt attached to it.

LPA reviewed two staff files, and five resident files. Resident files had all required documents, however two of two staff did not have their physical exams available for review. A deficiency will be issued on today's date. Staff training was up to date and documented. LPA reviewed medication administration record and medications with facility staff; per LPA review mediations are stored away and inaccessible to residents in care. Per LPA review medications are being administered per physicians orders.

Based on observations made during today's inspection deficiencies will be issued on today's date An exit interview was conducted and a copy of this report was provided to facility staff.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/05/2026 04:45 PM - It Cannot Be Edited

Created By: William Vanegas On 02/05/2026 at 04:33 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	FACILITY NUMBER: 306005865
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onrecord review, the licensee did not comply with the section cited above in two of two staff members not having a health screening and T.B test available for review. Which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/19/2026
	Plan of Correction
1 2 3 4	Administrator agrees to assign employees to receive a health screening and T.B test as soon as possibble. Administrator will send proof of correction to LPA via email by P.O.C due date.

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.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC809 (FAS) - (06/04)

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