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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006095
Report Date: 05/01/2025
Date Signed: 05/01/2025 05:06:01 PM

Document Has Been Signed on 05/01/2025 05:06 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:EPIC ASSISTANCE CARE HOMEFACILITY NUMBER:
306006095
ADMINISTRATOR/
DIRECTOR:		MESDJIAN, LIZAFACILITY TYPE:
740
ADDRESS:26751 CARRETAS DRIVETELEPHONE:
(818) 220-0282
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
05/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Liza Mesdjian, administrator (via phone)TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Liza Mesdjian was notified via telephone and was unable to attend the visit in person but was presented with the present report over the phone before agreeing to have a staff member sign on her behalf.

There are currently six residents in care, two of which are receiving hospice care at this time. LPA observed residents relaxing in the facility's common living areas or in their respective bedrooms. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has six private rooms along with one staff room. There are two shared bathrooms as well as multiple en-suite half bathrooms throughout the facility.

Bedrooms appear clean and sanitary. Two residents are currently using half-rails for postural support. A third resident sleeps in a bed equipped with full rails. Appropriate physician orders and/or hospice plans of care on file for all three residents. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Hot water temperature measured at 119F in one bathroom and one half-bathroom with faucets used for personal grooming. A third measurement in the second shared bathroom was found to be 138F. Water heater adjusted during the visit. Type B citation issued.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning products and the medication central storage all verified to be secured.
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: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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 05/01/2025 05:06 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 05/01/2025 at 04:24 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: EPIC ASSISTANCE CARE HOME
FACILITY NUMBER: 306006095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and measurements conducted during the visit, the licensee did not comply with the section cited above as one faucet was found to deliver water at 138F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Facility is equipped with two water heaters, one of which required to be adjusted. Temperature lowered during the visit.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interviews and records reviewed, the licensee did not comply with the section cited above as two staff members on duty during the visit did not possess a current CPR/First Aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Licensee to schedule adequate CPR/First Aid training to ensure the presence of at least one trained staff member per shift at all times. Proof of training to be provided before the plan of corrections 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/01/2025 05:06 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 05/01/2025 at 04:24 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: EPIC ASSISTANCE CARE HOME
FACILITY NUMBER: 306006095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025

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 section cited above in spite of a Technical Violation Advisory Note issued in May 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Licensee to obtain an adequately sized poster and replace the small version on display before the plan of corrections 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


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: EPIC ASSISTANCE CARE HOME
FACILITY NUMBER: 306006095
VISIT DATE: 05/01/2025
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CONTINUED FROM FORM LIC809
Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The attached garage is inaccessible to residents and used for laundry as well as additional storage of food and supplies.

LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. There are self-latching gates on both sides of the property and the routes of egress are free of clutter and obstructions. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress.

LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. One resident's assessment however indicates that he needs assistance with self-administration of medication. There is a physician note on his medication list stating that he may manage his own supplements and vitamins, however medication and ointments are also present in the room. Staff is provided with a Technical Violation Advisory Note informing them that the resident's assessment needs to be more precise in defining which substances are safe for the resident to handle. Information on the updated requirements for an annual medical assessment also provided. The RCFE Complaint poster PUB475 is also observed to be printed on an 8x10 sheet of paper rather than the required 20x26. Type B deficiency cited.

Oxygen is not currently in use. There are no bedridden residents present on the premises. LPA reviewed staff records for two caregivers present. None of the two staff members has a current CPR/First aid certificate. Type B deficiency cited. Initial and annual training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Disaster drills are conducted quarterly.

Based on the observations made during today’s visit, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative along with appeal rights
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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