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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006134
Report Date: 11/04/2025
Date Signed: 11/04/2025 11:44:56 AM

Document Has Been Signed on 11/04/2025 11:44 AM - 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:VIA LA CORUNA MANORFACILITY NUMBER:
306006134
ADMINISTRATOR/
DIRECTOR:		MCKEEVER, KAYLAFACILITY TYPE:
740
ADDRESS:23911 VIA LA CORUNATELEPHONE:
(714) 770-7669
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
11/04/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Eleazar CuysonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On November 4, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced case management visit for a Health & Safety check. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Eleazar Cuyson was notified via telephone and later arrived to assist with the inspection.

On today's visit, LPAs observed five residents in care and two staff present. LPAs observed residents watching television in the living room. LPAs observed residents to be in clean clothes. LPAs, accompanied by the AD, conducted a tour of the physical plant. LPAs inspected the four resident bedrooms and observed them to be free of hazards. LPAs observed residents' bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed the lights in each of the resident bedrooms to be operational. The water and toilets in each of the resident bathrooms were operational. The hot water temperature measured 108.3 degrees Fahrenheit.

LPAs observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPAs observed kitchen appliances to be clean and operational. LPAs observed the four burner gas stove lights unassisted. LPAs observed the facility has a three day emergency food and water supply stored in the pantry by the kitchen. No health or safety concerns were observed. LPAs additionally conducted interviews with three staff and five residents.

LPAs advised the AD of the outstanding annual fee balance of $494.50. During the visit, LPAs requested the current liability insurance for the facility. Two staff interviews confirmed that the facility did not currently have liability insurance and that the liability insurance was not renewed when the previous policy expired. Continued on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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: VIA LA CORUNA MANOR
FACILITY NUMBER: 306006134
VISIT DATE: 11/04/2025
NARRATIVE
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Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted Administrator Eleazar Cuyson. A copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2025 11:44 AM - It Cannot Be Edited


Created By: Garlli Tat On 11/04/2025 at 11:21 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: VIA LA CORUNA MANOR
FACILITY NUMBER: 306006134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2025
Section Cited
HSC
1569.605

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1569.605: Liability insurance; coverage requirements: ... all residential care facilities for the elderly, ... shall maintain liability insurance ... in the amount of ... ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, ..... This requirement is not evidenced by:
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The Licensee stated that she is in the process of obtaining liability insurance for the facility. The Licensee stated that she will provide proof of the liability insurance once it has been obtained to LPA via email or fax by POC date.
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Based on observation and interview, the Licensee did not ensure that the facility currently has liability insurance. Two staff interviews conducted confirmed the facility does not have liability insurance. This poses an immediate health and safety 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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