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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006039
Report Date: 09/23/2025
Date Signed: 09/23/2025 02:54:00 PM

Document Has Been Signed on 09/23/2025 02:54 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:TRADITIONS AT LUCERO WAYFACILITY NUMBER:
306006039
ADMINISTRATOR/
DIRECTOR:		REYES, LORDELE DE LOSFACILITY TYPE:
740
ADDRESS:17801 LUCERO WAYTELEPHONE:
(714) 769-5858
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
09/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:59 AM
MET WITH:Lordele De Los Reyes - Administrator TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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 On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. Licensee/Administrator Lordele De Los Reyes arrived at 8:45am.

The facility is a 7 bedroom, 3.5 bathroom single story home with an attached garage. The facility is licensed for 5 non-ambulatory residents and 1 bedridden resident in room #6 only. The facility has a hospice waiver for 4 residents and currently has 2 residents on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 105 to 105.8 degrees. All smoke detectors were operational. The facility’s last fire drill was conducted on June 1, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed 5 different food items that were expired dates ranging from September 2022 to April 2025 found in kitchen cabinets. LPA did not observe a PUB 475 in regulation size or facility license posted in the facility.



LPA reviewed 5 out of 5 resident files. LPA observed 5 out of 5 residents did not have a signed admission agreement. LPA observed 5 out of 5 residents did not have an appraisal conducted at admission or an updated appraisal. LPA observed 3 out of 5 residents did not have an updated medical assessment.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observation Administrator Lordele De Los Reyes stated facility could not produce liability insurance.
POC Due Date: 09/24/2025
Plan of Correction
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Administrator stated will produce a copy of liability insurance to LPA by POC due date.
Type A
Section Cited
CCR
87355(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews the licensee did not comply with the section cited above in 1 out of 3 staff members which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Corrected during visit. An immediate civil penalty assessed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the licensee did not comply with the following in 1 out of 5 residents as Resident 1 on LIC 858 did not have results of TB test on record. This poses an immediate health and safety risks to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to obtain negative tb test for R1 and provide proof to LPA by POC due date.
Type A
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 records reviewed the licensee did not comply with the above in 5 out of 5 residents as no apprasials were conducted or updated as needed. This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to complete appraisals for all 5 residents and provide proof 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the Licensee did not comply with the following in 3 out of 5 residents as 3 residents did not have any updated medical assessment or documentation of visits. This poses an immediate health and safety risks to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Licensee agreed to obtain updated physician's reports for the 3 residents in care and provide proof to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Licensee did not maintian staff records at the facility in 2 out of 3 staff members, This poses a potential health and safety risks to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Corrected during visit. Licensee brought files to facility and agreed to maintain facility staff files on premises.
Type B
Section Cited
CCR
87412(a)(11)
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
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Based on records reviewed the licensee did not comply with the following in 2 out of 3 staff members as they did not have a health screening on record. This poses a potential health and safety risks to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee agreed to have staff retain a health screening on record and provide proof to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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 cited above as the licensee does not have PUB 475 in regulation size of 20X 26.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee to obtain PUB 475 in regulation size and provide proof to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/23/2025 02:54 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/23/2025 at 01:18 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: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the cited above as there were expired food items (seasonings and instant mashed potatoes) in kitchen cabinets. This poses a potential health risks to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Corrected during visit. Licensee agreed to conduct quarterly checks on food expiration dates and keep records of dates.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the licensee did not compy with the cited above as 5 out of 5 residents' admission agreements were missing facilty representative's signature. This poses a potential personal rights risks to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee agreed to sign all admission agreements and provide proof by POC due date. Licensee agreed to implement a check list for pre admission paperwork.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TRADITIONS AT LUCERO WAY
FACILITY NUMBER: 306006039
VISIT DATE: 09/23/2025
NARRATIVE
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LPA Mendivil requested a copy of facility liability insurance and Administrator was not able to produce a copy. LPA reviewed 3 out of 3 staff members files, 2 out of 3 staff did not have a health screening on record. LPA Mendivil observed 1 out of 3 staff member's criminal clearance not associated to the facility. LPA Mendivil confirmed Administrator certificate expires on October 6th 2025.

LPA Mendivil consulted with Administrator Lordele regarding reporting requirements, the importance of documentation and time administrator spends at the facility.

Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report, appeal rights, LIC 858 and LIC 859, LIC 421 BG provided to the facility representative.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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