306006031-9-2-2025-22-AS-BLOZ-DL5UPJ-20250902154538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006031
Report Date: 09/02/2025
Date Signed: 09/02/2025 03:46:39 PM

Document Has Been Signed on 09/02/2025 03:46 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:	PORT MINOA		FACILITY NUMBER:	306006031
ADMINISTRATOR/ DIRECTOR:	ROCHE, RYAN		FACILITY TYPE:	740
ADDRESS:	25601 MINOA DRIVE		TELEPHONE:	(949) 916-9228
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 3	DATE:	09/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator Scott Messick		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	On September 2, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (ADs) Scott Messick was notified via telephone and later arrived to assist with the inspection. LPAs observed that Scott Messick has a valid Administrator certificate which expires on December 1, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, and has a hospice waiver for six. The facility is a single-story home with five resident bedrooms, one of which is shared, one staff bedroom, two resident bathrooms, a living room, a dining room, a kitchen, a laundry room, a staff office, and an attached two car garage. LPAs accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPAs observed three residents in care and two care giving staff present. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the five resident bedrooms, and they were observed to be free of any hazards. LPAs observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPAs observed additional linens are stored in the hallway cabinets. LPAs inspected the two resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 107.9 and 108.1 degrees Fahrenheit. LPAs observed the staff bedroom can be kept locked. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025

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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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: PORT MINOA	FACILITY NUMBER: 306006031
	VISIT DATE: 09/02/2025

NARRATIVE

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LPAs observed kitchen appliances to be clean and operational. LPAs observed kitchen knives are stored in a locked kitchen cabinet. LPAs observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink.

Fire extinguishers are located in the kitchen and in the garage. Fire extinguishers were observed the be charged and serviced as of April 4, 2025. LPAs tested the wired smoke detectors and carbon monoxide detectors which tested operational. LPAs observed the facility conducted their last emergency disaster drill on July 3, 2025. The centrally stored medication is kept in a locked closet by the resident hallway. LPAs also observed a First Aid Kit to be stored in the closet. The door leading to the laundry room was kept locked and inaccessible to residents in care. LPAs 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. LPAs observed chemicals and toxins to be stored in the garage. LPAs observed the facility has an three day emergency food and water supply stored in the garage.

LPAs and AD conducted a tour of the exterior portion of the facility. LPAs observed the exterior portion to be clear of obstructions and hazards. LPAs observed a shaded outdoor seating area with furniture for resident use. The perimeter gate is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed all three resident files. All the required documentation were present and current in the resident files reviewed. LPAs reviewed residents’ medication and medication records. LPAs reviewed three staff files. All staff are background cleared and associated to the facility.

Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Scott Messick and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025

LIC809 (FAS) - (06/04)

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