<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006485
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:34:25 PM

Document Has Been Signed on 07/22/2024 03:34 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLS OF VIA DEL SOL, THEFACILITY NUMBER:
306006485
ADMINISTRATOR/
DIRECTOR:		CUYSON, ELEAZARFACILITY TYPE:
740
ADDRESS:26462 VIA DEL SOLTELEPHONE:
(714) 430-7672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
07/22/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:50 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) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Licensee Maricel Nepomuceno. Administrator Eleazar Cuyson was present as well. An initial application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing on 01/12/2024 for a capacity of six non-ambulatory residents. Upon entry, facility appears clean and sanitary. Facility has all required postings at entrance. Administrator Eleazar Cuyson has an administrator certificate expiring on 05/27/2026. This pre-licensing is a change of ownership with five residents present during today's visit.
LPA Lyman along with Licensee/ Administrator toured the facility at 12:14 PM and observed the following:
Structure: Facility is a two story, 4 bedroom, 2 bathroom house on first floor and two bedrooms, living area and two baths on the second floor. There is an attached garage and a white exterior. Second story is reserved for staff. The outside exit gates are closed, self latching, and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be single and double occupancy and housed on the first floor only. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Auditory exit alarms are operational. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguisher is fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 110.6 and 111.3 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 07/22/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF VIA DEL SOL, THE
FACILITY NUMBER: 306006485
VISIT DATE: 07/22/2024
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
26
27
28
29
30
31
32
LPA observed a first aid manual. Medication is stored in a locked cabinet. Facility uses a medication administration record. Resident & Staff File: Records are stored in a secured file cabinet in the kitchen. Reading Material, Games, and Equipment: LPA observed an activity schedule with activities such as games, music therapy and exercise. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Facility has a secured empty pool with a 55 inch fence around it Fire Clearance: Approved for six non-ambulatory residents on 06/19/2024.


Component III waived due to multiple facilities in Orange County. Facility is ready to be licensed.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2