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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006446
Report Date: 07/29/2025
Date Signed: 07/29/2025 05:29:46 PM

Document Has Been Signed on 07/29/2025 05:29 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:PERPETUAL LOVE SENIOR LIVINGFACILITY NUMBER:
306006446
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, FREGILFACILITY TYPE:
740
ADDRESS:18480 SANTA ALBERTA CIRCLETELEPHONE:
(714) 332-7051
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Camille Santos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On July 29, 2025, at 2:00pm, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced
required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was
greeted and granted entry by Administrator (AD) Fregil Jimenez and Administrator (AD) Camille Santos later joined the inspection. LPA stated the purpose of the visit and requested Resident/Staff rosters and Personnel Record.

The facility is licensed to operate for six (6) non-ambulatory residents, of which one (1) may be bedridden, and
has a hospice waiver for two (2) residents. The facility is a single-story building located in a residential
neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, two living room areas, dining area, kitchen, an outdoor covered seating area, and an attached two car garage.

LPA Bentley toured inside and outside of the physical plant with AD Pascual. There are no obstructions on the premises. There is a large, covered fish tank in the front living room. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature measured 130.1 degrees F to 130.4 degrees F and a deficiency is being cited.

CONTINUE ON LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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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Document Has Been Signed on 07/29/2025 05:29 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/29/2025 at 04:53 PM
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: PERPETUAL LOVE SENIOR LIVING
FACILITY NUMBER: 306006446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the water temperature in the common client bathroom tested at 130.1 and 130.4 degrees F, which poses a immediate safety risk to persons in care. LPA observed elevated water temperature in two out of two bathrooms used by residents in care.
POC Due Date: 07/30/2025
Plan of Correction
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During the inspection the licensee corrected the water temperatures and LPA confirmed by retesting. Licensee stated they will submit water temperature logs to LPA/CCLD via email by 5pm on POC due date, along with pictures of thermometer. Logs will include water readings for both bathrooms taken every two hours for the next 24 hours.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA toured Resident 1 (R1) bedroom with AD Santos and AD Jimenez and observed multiple medications unsecured on tray table, near R1 bed. AD Santos stated resident prefers to take medication on her own, as needed and later stated there was no doctor's order for R1 to self-administer medication. This poses an immediate health and safety issue for residents in care.
POC Due Date: 07/30/2025
Plan of Correction
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LPA observed AD Santos remove remove and secure R1 medication. Licensee will ensure that all medications are kept in secure location and inaccessible to residents. Licensee will provide in service training to all staff on section cited above. Licensee will forward proof of training to LPA via email by 5pm on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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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: PERPETUAL LOVE SENIOR LIVING
FACILITY NUMBER: 306006446
VISIT DATE: 07/29/2025
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LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.

During the visit, LPA Bentley observed all mandated inspection control posters were posted. A comfortable
temperature of 76 degrees F was maintained in the facility. The smoke detectors and carbon monoxide
detectors were operable. A working telephone (714-968-6042) remains available, and the facility has a device
that can be used for video teleconference purposes. Emergency food, emergency water, and emergency
supplies were stored in the garage. The facility has four (4) fire extinguishers that were charged, mounted, and serviced on May 29, 2025. Liability Insurance is effective November 21, 2024, and expires on November 21, 2025. Emergency safety drills were last conducted on June 20, 2025, and conducted quarterly. First aid kit is maintained and contains all the necessary elements.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), four (4) staff files (S1-S4), and a medication and medication administration review. LPA Bentley conducted two (2) staff interviews and five (5) resident interviews. During tour LPA Resident 1 (R1) bedroom with AD Santos and AD Jimenez and observed multiple medications unsecured on tray table, near R1 bed. LPA observed AD Santos remove and secure R1 medication

Based on observations, interviews and record reviews, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrators
Camille Santos and Fregil Jimenez at the end of the visit..
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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