306006273-6-5-2025-22-AS-JALE-DHCPXU-20250605114256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006273
Report Date: 06/05/2025
Date Signed: 06/05/2025 11:43:16 AM

Document Has Been Signed on 06/05/2025 11:43 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:	EPIC ASSISTANCE CARE HOME #2		FACILITY NUMBER:	306006273
ADMINISTRATOR/ DIRECTOR:	MESDJIAN, LIZA		FACILITY TYPE:	740
ADDRESS:	25464 VIA ESTUDIO		TELEPHONE:	(949) 218-7268
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 6		CENSUS: 6	DATE:	06/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Yoga Fadhlullah		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with staff and explained the reason for the visit. The Administrator, Liza Mesdjian's Administrator's certificate expires on July 29, 2026. LPA and staff toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. The facility is a single story home with 6 bedrooms, 4 bathrooms, living room, dining room, kitchen and a 2 car garage. LPA observed the fireplace in the living room is screened. LPA toured the kitchen and dining room. The kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed that the left rear burner on the stove does not light unassisted. LPA observed the knives are kept locked in a kitchen drawer. LPA observed the fire extinguisher in the dining room is fully charged. LPA toured the resident rooms. LPA observed all resident rooms are clean and organized. All resident beds had the required linens. LPA observed all 4 bathrooms are clean and operational. LPA observed the exhaust fan in bathroom for bedroom 6 is not operational. How water measured 105.0 degrees Fahrenheit in all 4 bathrooms. Smoke detectors/carbon monoxide detectors tested operational. The last fire drill was conducted on April 15, 2025. LPA toured the garage. The garage is used for storage and kept locked. LPA observed extra furniture, supplies and perishable food stored in the garage refrigerator. LPA observed a 3 day emergency food and water supply stored in the garage. The living room has chairs for residents to sit and there is a TV mounted above the fireplace for residents to watch TV. LPA observed reading material and games stored on the shelf in the dining room. LPA observed the medication is stored in the locked closet next to bedroom number 2. LPA toured the backyard. LPA observed a covered patio in the backyard. No bodies of water observed. The exit gate is operational and is self closing. There is a courtyard at the front of the house that has a seating area with shade so the residents can sit outside. No obstacles or hazards observed inside or outside of the facility.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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: EPIC ASSISTANCE CARE HOME #2	FACILITY NUMBER: 306006273
	VISIT DATE: 06/05/2025

NARRATIVE

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LPA reviewed 4 staff files, no discrepancies observed. The 4 staff had the required 20 hours of annual training. All 4 staff members are background cleared and associated to the facility. LPA reviewed 6 resident files and medications, no discrepancies observed. Smoke detectors and the carbon monoxide detectors tested operational. LPA inspected the first-aid kit. The first-aid kit had all the required elements. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2025 11:43 AM - It Cannot Be Edited

Created By: Joseph Alejandre On 06/05/2025 at 11:16 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: EPIC ASSISTANCE CARE HOME #2	FACILITY NUMBER: 306006273
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: LPA observed the exhaust fan in the bathroom of bedroom 6 does not operate and the left rear stove burner does not light unassisted.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have the bathroom exhaust fan and the left rear stove burner repaired and/or replaced by the POC due date. Licensee to forward proof of repair to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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