306006360-8-25-2025-22-AS-RMAZ-DKVS92-20250825134001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006360
Report Date: 08/25/2025
Date Signed: 08/25/2025 01:40:14 PM

Document Has Been Signed on 08/25/2025 01:40 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:	WATERMARK LAGUNA NIGUEL		FACILITY NUMBER:	306006360
ADMINISTRATOR/ DIRECTOR:	HOWLAND, JAMES		FACILITY TYPE:	740
ADDRESS:	27762 FORBES ROAD		TELEPHONE:	(949) 899-8175
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 135		CENSUS: 58	DATE:	08/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:20 AM
MET WITH:	Ashley Davidson, Resident Care Director		TIME VISIT/ INSPECTION COMPLETED:	01:55 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	Licensing Program Analysts (LPAs) Ruth Martinez and Garlli Tat made an unannounced visit to conduct the required annual inspection. LPAs met with Ashley Davidson, Resident Care Director and explained the reason for the visit. LPAs and the Resident Care Director toured the facility. Facility is licensed for 55 ambulatory, 68 non-ambulatory, and 12 bedridden residents. Facility has an approved hospice waiver for 25 residents. Delayed egress approved for 1st floor. This facility consists of two main areas. The assisted living and the memory care which is on the 1st floor. Memory care unit protected by delayed egress exits. Facility is a three story building with 78 Assisted Living resident rooms and 38 Memory Care resident rooms. The facility also houses 2 courtyards, a living room on each floor, a bistro, 2 dining rooms, 2 community patios, Staff break room, a Med rooms on each floor and a parking structure. LPAs and Resident Care Director began the tour of the physical plant of the facility. LPAs observed the memory care has a secured perimeter and delayed egress. The delayed egress exits were tested and found to be operational. The memory care is on the first floor and has a dining area, activity room and outdoor patio with shaded seating. LPAs toured the resident rooms in memory care. The resident rooms toured had all the required furnishings. There is an activity room with puzzles and games along arts and crafts supplies. There is a Large screen TV mounted on the wall in the activity room. No obstacles or hazards observed in the memory care. LPAs and the Resident Care Director toured the assisted living which is on the second and third floors. LPAs observed each stairway has an emergency evacuation chair. LPA observed the kitchen is clean and organized. LPA observed a bistro adjacent to the main dining room where residents can obtain Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

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: WATERMARK LAGUNA NIGUEL	FACILITY NUMBER: 306006360
	VISIT DATE: 08/25/2025

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different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. The emergency food and water supply is stored in a storage room. LPA observed the refrigerators and freezer are at the required temperatures. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms were tested for water temperature in floors 1-3 and water temperature measured between 115.7 and 118.5 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPAs pushed the restroom call button in various resident rooms and response times were under five minutes. LPAs observed several residents who appeared clean, and happy. There are activity rooms with games and reading materials on the second and third floor. Each activity room has a large screen TV. The assisted living section has a courtyard on the first floor with shaded seating. No bodies of water observed. There is also shaded balconies on the second and third floor for assisted living residents. No obstacles or hazards observed in the assisted living section.

Fire extinguishers are fully charged and mounted throughout the facility. Smoke detectors and sprinkler system are tested by an outside agency, and LPAs was provided with testing documentation, last testing was done July 25, 2025. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room on each floor. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care, no discrepancies observed. LPAs reviewed 6 resident files, no discrepancies observed. LPA reviewed 5 staff files. All staff had the required training. No discrepancies observed. Staff members present are background cleared and associated to the facility.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025

LIC809 (FAS) - (06/04)

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