306006637-5-13-2025-22-AS-JALE-DGMULV-20250513154123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006637
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:41:32 PM

Document Has Been Signed on 05/13/2025 03:41 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 SENIOR LIVING LLC		FACILITY NUMBER:	306006637
ADMINISTRATOR/ DIRECTOR:	MOTTER, MARY DEE		FACILITY TYPE:	740
ADDRESS:	25011 MONTE VERDE DR		TELEPHONE:	(619) 992-0854
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 6		CENSUS: 4	DATE:	05/13/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:04 PM
MET WITH:	Mary Dee Motter		TIME VISIT/ INSPECTION COMPLETED:	04:25 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) Joseph Alejandre made an unannounced visit to conduct the pre-licensing inspection. LPA met with applicant Mary Dee Motter. An initial application to operate an Residential Care Facility for the Elderly (RCFE) for 6 non-ambulatory residents was submitted to Community Care Licensing (CCL) on September 6, 2024. Structure. The facility is a one story house with 6 bedrooms, 1 staff room, 6 bathrooms, living room, laundry room, kitchen, dining room and an attached 2 car garage. LPA observed games and puzzles stored in cabinets in the activity rooms. LPA observed the fire extinguisher in the laundry room is fully charged. LPA observed the fireplace in the living room has been closed and is no longer operational. LPA observed the See Something, Say Something sign posted next to the front door. Facility phone number is 949-503-1939. Furniture, LPA observed all the resident rooms have the required furnishings. Bathrooms. Facility has 6 bathrooms and all bathrooms are clean and operational. Water Temperature. LPA measured the hot water at 111.9 degrees Fahrenheit. Emergency Phone Numbers & Exit Plan. Posted at the main entry of the facility. Appliances. LPA observed the cook-top stove, oven and refrigerator are all clean and operational. Food Service. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the ktichen. Toxins and cleaning supplies are kept locked in the garage. Clients & Staff Files are stored in a cabinet in the dining room. Medications are kept locked in a kitchen cabinet. First-Aid Kit & Book are kept in the linen closet. LPA observed the first aid kit has all the required elements. Reading Material, Games, Equipment & Materials. There are board games and reading material in the living room.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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: LAGUNA SENIOR LIVING LLC	FACILITY NUMBER: 306006637
	VISIT DATE: 05/13/2025

NARRATIVE

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Fire clearance, the fire clearance was approved by Orange County Fire Authority on October 30, 2024 for 50 ambulatory clients. Backyard. LPA observed no bodies of water. There is a table with an umbrella and chairs for residents to sit outside The exit gate is latched and operational. No obstacles or hazards observed in the backyard. Smoke Detectors/Carbon monoxide detectors tested operational. Component III: Conducted with the applicant. Information provided on how to operate the facility in compliance with Title 22.

No deficiencies observed. The facility is ready to be licensed. LPA informed the applicant that final approval for licensure will be approved by CAB in Sacramento.

Exit interview was conducted and a copy of this report was provided to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

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