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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006586
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:18:03 PM

Document Has Been Signed on 10/17/2024 12:18 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:LAGUNA HILLS GUEST HOMEFACILITY NUMBER:
306006586
ADMINISTRATOR/
DIRECTOR:		SOLOMON, MICHELLEFACILITY TYPE:
740
ADDRESS:23636 MESSINATELEPHONE:
(714) 227-6973
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Michelle Solomon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Samer Haddadin made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPAs were greeted and granted entry by Michelle Solomon, administrator.

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on May 30, 2024 for a capacity of six non-ambulatory residents. This is a change of ownership with five residents already in care. Three of the currently admitted individuals are receiving hospice care. The applicant has requested a hospice waiver for six residents.

LPAs accompanied by administrator toured the physical plant. The facility is a one-level home with a frontyard, backyard and attached garage. There are two shared bedrooms and two private bedrooms with one shared bathroom and one en-suite bathroom attached to one of the shared rooms. Each of the bedrooms include all necessary components of furnishing including a light, chair, storage space for personal items and a full-size bed as well as a supply of linen and bedsheets. Water temperature was measured within acceptable range at 110.7F. Common living spaces are present and a device connected to the internet is present for the use of the residents in care. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present.

Kitchen equipment is present and operating as required. Sharp items and cleaning supplies are confirmed to be secured. A sufficient supply of perishable and non-perishable food is present as required by Title 22 Regulations. The centrally stored medication storage is located in a secure cabinet. The garage is used for additional storage. The laundry area is located in a central hallway, cleaning supplies are locked in the cabinet above. The entrance to the garage is also secured. Sound alarms are present on the ways of egress.

CONTINUED ON FORM LIC809-D
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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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: LAGUNA HILLS GUEST HOME
FACILITY NUMBER: 306006586
VISIT DATE: 10/17/2024
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CONTINUED FROM FORM LIC809
Staff and five client records were reviewed and confirmed to include all necessary components.

The fire clearance has been obtained on June 19, 2024 and provided to the Department before the pre-licensing visit. Combined smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. Fire extinguishers present on the premises are observed to be charged with current maintenance tags. First aid kit verified to be complete. First aid manual present.

LPAs and licensee toured the outside of the facility and observed it to be free of obstructions. One shaded area is present in the backyard and is equipped with outdoor furniture for the enjoyment of residents and visitors. The perimeter gates present on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Component III was waived as the prospective licensee has already been acting as the current facility administrator and operates other licensed locations as well. This report was reviewed with facility representative and a copy of this report was emailed to the applicant before the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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