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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006118
Report Date: 03/25/2026
Date Signed: 03/25/2026 12:51:23 PM

Document Has Been Signed on 03/25/2026 12:51 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:HILLS OF SHAY DEL, THEFACILITY NUMBER:
306006118
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:5982 SHAY DEL PLACETELEPHONE:
(626) 827-9547
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 5DATE:
03/25/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Caregiver- Joey SarmientoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On March 25, 2026, at 11:15 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim spoke with Administrator (ADMIN) Heddy Mae Oyson over the phone and explained the purpose of the visit. ADMIN Oyson stated they could not make it for today's visit and stated Caregiver (CG) Joey Sarmiento could sign in behalf of the facility.

LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to five residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The indoor temperature measured at 72 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities.

Facility did not notify Licensing, residents, and residents’ representatives that they received default notices of missed payments for the facility. LPA conducted interviews with three residents and two staff. The facility does not have current and valid insurance at the facility. As of today, the facility still has not provided current and valid insurance as agreed upon.

Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118
VISIT DATE: 03/25/2026
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Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. The facility did not notify licensing, residents, and residents’ representatives of the default notices received. The Licensee is receiving the same citation that was issued during a previous visit conducted on March 2, 2026. The Licensee has not corrected the deficiency for not having a current and valid insurance. A Civil Penalty is being assessed for Failure to Correct/Repeat Violations for not having current and valid insurance The total amount of Civil Penalties assessed today are $900.

An exit interview was conducted, and a copy of this report, LIC809D, appeal rights, and LIC 421FC were provided to Caregiver Joey Sarmiento.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2026 12:51 PM - It Cannot Be Edited


Created By: Edward Kim On 03/25/2026 at 11:25 AM
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2026
Section Cited
CCR
87211(d)(4)

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87211 Reporting Requirements (d) The licensee shall notify the Department... all residents, and... their representatives, in writing within two business days of any of the following... (4) The licensee receives a written notice of default of payment of rent...
This requirement is not met as evidenced by:
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Licensee to provide written notice to residents and their representatives of written notice they received regarding default on the mortgage for the facility and a copy of written notice to residents will be provided to LPA Edward Kim via email by POC due date March 26, 2026.
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Based on Licensee interview, Licensee did not comply with the section cited above as they received notice of default on the mortgage for the facility due to being five months behind on mortgage payments and they have not provided any written notice to any resident or their family.
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Type A
03/26/2026
Section Cited
HSC1569.605

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Liability insurance; coverage requirements: ..all residential care facilities for the elderly.. shall maintain liability insurance covering injury to residents and guests...

This requirement was not met evidenced by
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Licensee stated they will provide required insurance and to provide proof to CCLD via email edward.kim@dss.ca.gov by POC due date March 26, 2026.
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Based on observation, interviews, and records reviewed, the Licensee did not ensure there was RCFE liability insurance for the facility. This poses an immediate health, safety, and personal rights risk to persons 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2026


LIC809 (FAS) - (06/04)
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