306006393-1-30-2026-22-AS-WVAS-DQTRFN-20260130115925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006393
Report Date: 01/30/2026
Date Signed: 01/30/2026 11:59:31 AM

Document Has Been Signed on 01/30/2026 11:59 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:	GRANNY'S PLACE #4		FACILITY NUMBER:	306006393
ADMINISTRATOR/ DIRECTOR:	NESBITT, MICHELLE		FACILITY TYPE:	740
ADDRESS:	25665 SABINA AVENUE		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	01/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Kimberly Arnett Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 today's date January 30,2026 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. LPA explained the nature of the visit Assistant Administrator Kimberly Arnett and Administrator Michelle Nesbitt were notified via telephone and joined later to assist with the tour. LPA began a tour of the facility and observed the following. This is a one storied home with seven bedrooms one of which is a care giver room, and six of which are resident rooms. Additionally the facility has four and a half bathrooms two of which are private, two of which are shared, and a half bath for staff and guests. Administrator has a valid Administrator certificate posted on the entry way wall that is set to expire on April 11, 2026. There are six residents at the facility and two are receiving hospice. LPA observed the PUB 475 (see something say something) poster and Long-Term Care Ombudsman poster posted at the entry way of the facility. All required department postings were observed to be posted on the entry way walls. LPA observed kitchen area to be clean and free of any mildew or debris. LPA Vanegas observed there to be an electric stove, refrigerator, microwave, washer, dryer, and dishwasher. All tested operational. LPA Vanegas observed there to be a two day supply of perishable food and a seven day supply of non-perishable food on hand at the facility. LPA Vanegas observed a sufficient amount of emergency food and water at the facility. LPA Vanegas observed resident bathrooms to have all required furnishings such as non-skid floor matts, grab bars, and shower chairs. Bathrooms are free of mildew and debris. Water faucets and toilets tested operational. Hot water temperature tested between 103.2 and 105.4 degrees Fahrenheit. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

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: GRANNY'S PLACE #4	FACILITY NUMBER: 306006393
	VISIT DATE: 01/30/2026

NARRATIVE

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LPA Vanegas observed client bedrooms to be clean and free of any hazards. LPA observed rooms to have all required furnishings such as a bed, clean linens in good repair; meaning no strains or tares, chest drawers, a reading lamp, and enough storage space to store personal belongings. LPA observed first aid kit to have all required items such as scissors, tweezers, adhesive tape, bandages, a thermometer, and a first aid manual.

LPA observed all fire extinguishers to be fully charged and up to date. LPA observed all smoke detectors and carbon monoxide detectors to be operational. LPA observed outside of the facility to have an outdoor shaded seating area. LPA Vanegas observed backyard to be clean and free of any hazards or objects blocking the exit routes. The side gates are self latching and unlocked.

LPA reviewed six resident files and four staff files. All files had required documents and annual staff training was up to date and documented. LPA Vanegas reviewed medication administration record (MAR) and medications. Per LPA review medications are being administered per physicians orders.

Based on observations made during today's inspection no deficiencies will be issued per title 22 division 6 of the California Code of Regulations. An exit interview was conducted with AD Kimberly Arnett and a copy of this report was provided to the facility and a copy of this report will be mailed to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

LIC809 (FAS) - (06/04)

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