306006329-6-6-2025-22-AS-KSGH-DHDVRM-20250606164009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006329
Report Date: 06/06/2025
Date Signed: 06/06/2025 04:41:15 PM

Document Has Been Signed on 06/06/2025 04:41 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:	FLORESTA COTTAGE		FACILITY NUMBER:	306006329
ADMINISTRATOR/ DIRECTOR:	MANIAGO, MARIE JOYCE M.		FACILITY TYPE:	740
ADDRESS:	26982 FLORESTA LANE		TELEPHONE:	(917) 386-5767
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	06/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Marie Maniago, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:55 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	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 Marie Maniago was notified of the visit via telephone and arrived later to assist. There are currently six residents in care, one of which is receiving hospice care at this time. LPA observed residents relaxing 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 bedrooms and two bathrooms. Bedrooms appear clean and sanitary. There are no residents requiring the use of postural supports at the time of the visit. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 111F and 114F in two separate bathrooms equipped with faucets used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secured. Fire extinguisher present is charged with up-to-date purchase receipt. Smoke and carbon monoxide detectors were found to be operational. The garage is secured and used for laundry as well as additional storage of supplies. Emergency food and water supplies verified to be present. 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: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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: FLORESTA COTTAGE	FACILITY NUMBER: 306006329
	VISIT DATE: 06/06/2025

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CONTINUED FROM LIC809
LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. The identified route of egress is free of clutter and obstructions. There is an adequately fenced swimming pool on the premises. There are egress alarms on all exit doors, however facility does not utilize locked perimeters or delayed egress as notified to residents and responsible parties.

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. There are no residents currently assessed as being bedridden at the time of the visit. Resident interviews were conducted or attempted during the visit along with staff interviews.

LPA reviewed staff records for three staff members present during the visit. CPR training, initial and annual training reviewed. Disaster drills are conducted quarterly and documented. Staff members are verified to be background cleared and associated to the licensed location.

Based on the observations made during today’s visit, no 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.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC809 (FAS) - (06/04)

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