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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006113
Report Date: 03/12/2026
Date Signed: 03/12/2026 05:17:38 PM

Document Has Been Signed on 03/12/2026 05:17 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:MILES PLACE OF FOUNTAIN VALLEY 2FACILITY NUMBER:
306006113
ADMINISTRATOR/
DIRECTOR:		DARYLL AVENDANOFACILITY TYPE:
740
ADDRESS:9367 SISKIN AVENUETELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
03/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Mark Cruz - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On March 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a Required-1 year annual inspection. LPA Bentley was greeted and granted entry by staff after stating gthe purpose of the visit. Administrator (AD) Mark Cruz arrived shortly after and was present to assist with the visit. Mark Cruz has an Administrator certificate with an expiration date of December 2, 2026.

The facility is licensed for age range 60 and over, with the for capacity of six (6) Non-Ambulatory residents, and has a hospice waiver for six (6) residents. There are currently four (4) residents present during today’s visit. The facility is a two-story house and the second story consists of: 4 bedrooms, and 3 bathrooms which are utilized for caregivers. The first floor consists of: 4 resident bedrooms; of which 2 bedrooms are shared bedrooms, 2 are private bedrooms, 3 bathrooms, living room, dining area, and kitchen.

LPA Bentley toured the interior and exterior of facility with staff, and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the residents’ personal belongings were observed in residents’ closets. Additional bed linens, comforters, and bath towels were available during the visit. The water temperature in 3 of 3 resident bathrooms were measured to be between 113.7 and 114.3 degrees Fahrenheit. Grab bars and non-slip mats were observed in all resident bathrooms. The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the stove. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed.

CONTINUE TO LIC-809C PAGE....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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: MILES PLACE OF FOUNTAIN VALLEY 2
FACILITY NUMBER: 306006113
VISIT DATE: 03/12/2026
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LPA observed two fire extinguishers mounted and charged in garage downstairs and hallway upstairs that were last serviced on March 5, 2025. There is also an additional fire extinguisher mounted and charged in downstairs hallway area, which was last serviced on August 13, 2025. Carbon monoxide detector and smoke alarms were tested and all operational.

The attached 2-car garage was observed clean and walkways were free of clutter and debris. A washer and dryer was found in working condition. LPA Bentley observed an adequate amount of emergency food and water supply. The backyard was clean and free of clutter and debris. The exit gate on the exterior of the home was self-latching and in operating condition.

LPA conducted a review of four residents service files (R1-R4), three (3) staff personnel files (S1-S3), and a review of the medication and Medication Administration Record (MAR), which was conducted and found to be within Title 22 California Code of Regulations. LPA Bentley conducted interviews residents and staff during the visit. The facility has liability insurance on file effective May 15, 2025 through May 15, 2026.

Based on the observations made during today’s visit, no deficiencies are being cited.

An exit interview was conducted with Administrator Mark Cruz, and a copy of this report provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
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