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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005934
Report Date: 07/28/2025
Date Signed: 07/28/2025 03:31:43 PM

Document Has Been Signed on 07/28/2025 03:31 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:ADULT CARE OC SATURNAFACILITY NUMBER:
306005934
ADMINISTRATOR/
DIRECTOR:		SCHOTT, BRIANFACILITY TYPE:
740
ADDRESS:24591 SATURNA DRIVETELEPHONE:
(949) 593-9290
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
07/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:Brian Schott, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of citing deficiencies observed during the investigation of complaint 22-AS-20230628144300 and not related to the allegations investigated.

There are six residents in care at the time of the present visit. LPA conducted a tour of the physical plant and requested resident records for all six residents in care. Per the review of records, one resident has been assessed to be bedridden, however the facility only has a fire clearance for six non-ambulatory residents. Type A citation issued and immediate civil penalty assessed.

During the investigation of the complaint mentioned above, staff member May Kwok was referred to on multiple occasions as the acting administrator (AA) for the facility. A review of background clearance and staff associations in Guardian demonstrates that AA Kwok criminal record clearance was not associated with the facility’. Type A citation and civil penalty assessed.

During the investigation, the death of a resident 1 dated December 24, 2022, and a fall incident resulting in fracture and hip replacement of resident 2 dated October 6, 2022, failed to be reported to licensing staff as required by regulations. Type B deficiency cited.

Additionally, it was confirmed that facility staff failed to implement adequate fall prevention planning and measures while providing care for facility resident R2. Type A citation issued.

CONTINUED ON FORM LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
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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Document Has Been Signed on 07/28/2025 03:31 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/25/2025 at 12:48 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: ADULT CARE OC SATURNA
FACILITY NUMBER: 306005934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2025
Section Cited
CCR
87355(e)(3)

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CCR 87355(e)(3) on Criminal Record Clearance “All individuals subject to a criminal record review (....) shall prior to working (...) in a licensed facility: (…) (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)”.
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Licensee stated they will associate AA criminal record clearance by the due date. The Licensee stated they will verify all staff associations for all current employees by POC due date and send confirmation to the LPA.
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This requirement is not met as evidenced by:
Per a review of the Guardian background clearance system, AA May Kwok was never associated to the present licensed facility. This constitutes an immediate risk to the health, safety and personal rights of individuals in care. Civil penalty assessed.
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Type A
07/29/2025
Section Cited
CCR87466

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Per CCR 87466: “The licensee shall ensure that residents are regularly observed for changes in physical (..) functioning and that appropriate assistance is provided when such observation reveals unmet needs.” This requirement is not met as evidenced by:
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POC: Licensee stated they will review the regulation and forward a statement of understanding to LPA by POC due date along with a fall prevention in-service training verification conducted with current facility staff.
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Based on records reviewed and interviews conducted, resident R2 had been identified as a fall risk, with multiple occurrences of fall prior and on October 6, 2022. The lack of adequate precautions resulted in the resident becoming injured and requiring surgery. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 03:31 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/25/2025 at 01:07 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: ADULT CARE OC SATURNA
FACILITY NUMBER: 306005934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2025
Section Cited
CCR
87217(d)(2)

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CCR 87217(d)(2) “Except as provided in approved continuing care agreements, no licensee or employee of a facility shall: accept any general or special power of attorney for any such person”
This requirement is not being met as evidenced by:
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Licensee stated they would review the regulations and provide documentation of understanding to LPA by POC due date.
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Based on record review and interview, Licensee failed to ensure an employee of the facility was not designated as a power of attorney for R1. This poses an immediate health and safety risk to residents in care.
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Type B
07/31/2025
Section Cited
CCR87211(a)(1)

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Per CCR 87211(a)(1) "A written report shall be submitted to the licensing agency (...) within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (A) Death of any resident from any cause regardless of where the death occurred"”
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Licensee indicated they would conduct an in-service training to staff in charge of reporting serious incidents and deaths. Documentation of training to be provided to the Department.
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This requirement is not met as evidenced by:
No death or incident reports corresponding to the incidents evidenced during the investigation were found to have been submitted to the Department.
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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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: ADULT CARE OC SATURNA
FACILITY NUMBER: 306005934
VISIT DATE: 07/28/2025
NARRATIVE
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CONTINUED FROM FORM LIC809
Finally, it was confirmed that AA had obtained power of attorney over the affairs of facility resident R2, which title 22 regulations clearly forbid. Type A citation issued.

Based on today’s visit, four type A deficiencies, one type B deficiency and two immediate civil penalties are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with a facility representative and a copy of this report along with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/28/2025 03:31 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/28/2025 at 02:26 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: ADULT CARE OC SATURNA
FACILITY NUMBER: 306005934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2025
Section Cited
CCR
87606(c)

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Per CCR 87606(c): "To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance." This requirement is not met as evidenced by:
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Licensee stated they would submit an updated LIC200 application form to request an update to the current fire clearance.
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Based on facility observation and records review, resident R3 is assessed as bedridden, however the current fire clearance for the facility does not include any provision for bedridden residents. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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