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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006637
Report Date: 04/28/2026
Date Signed: 04/28/2026 04:59:23 PM

Document Has Been Signed on 04/28/2026 04:59 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 LLCFACILITY NUMBER:
306006637
ADMINISTRATOR/
DIRECTOR:		MOTTER, MARY DEEFACILITY TYPE:
740
ADDRESS:25011 MONTE VERDE DRTELEPHONE:
(619) 992-0854
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 4DATE:
04/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Gertrudeslilia GarciaTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. Facility is licensed for 6 non-ambulatory residents and a hospice waiver for 6. 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. The Administrator's certificate expires on July 30, 2026. LPA and staff toured the facility. LPA observed the See Something Say Something Poster (PUB 475) posted in the entry way of the facility. LPA observed the fireplace in the living room is blocked off by a piece of wood that has moved mounted in the opening, so the fireplace is not accessible and cannot be used. LPA observed the 4 burner cook-top lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. Medication is kept locked in a cabinet in the kitchen. Smoke detectors/carbon monoxide detectors tested operational. Staff reported that last fire (disaster) drill took place in January but there is no documentation for any disaster drill. LPA and staff inspected the resident rooms. LPA observed all resident rooms had the required bed linens and furniture. LPA observed Resident 1 (R1) had bed rails. Staff reported that R1 is no longer on hospice. LPA observed all bathrooms are clean and operational hot water measured 107.9 degrees Fahrenheit in the 2 shared bathrooms. LPA observed the garage is kept locked and used for storage of extra food and supplies. LPA and staff toured the backyard. No bodies of water observed. There are two shaded areas with chairs to sit outside. The exit gate is operational. No obstacles or hazards observed in the backyard. LPA reviewed 4 resident files and medications. LPA observed R1 did not have a doctor's order for bed rails in their file. LPA observed R1 did not have a pre-appraisal or a current appraisal/care plan. No other discrepancies observed. LPA reviewed 2 staff files, LPA observed Staff 1 (S1) had a negative TB test but did not have a completed health screening.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
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 7
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: 04/28/2026
NARRATIVE
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Both staff members had the required training and CPR/First-Aid training. Both staff members are background cleared and associated to the facility. LPA observed facility does not have a internet device for dedicated resident use. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of the report provided to the facility representative along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/28/2026 04:59 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 04/28/2026 at 04:34 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: LAGUNA SENIOR LIVING LLC
FACILITY NUMBER: 306006637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, there is no record of a any disaster drill being conducted which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2026
Plan of Correction
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Licensee agrees to conduct a disaster drill and to document the drill in accordance with the regulation above. Licensee agrees to submit proof to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/28/2026 04:59 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 04/28/2026 at 04:34 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: LAGUNA SENIOR LIVING LLC
FACILITY NUMBER: 306006637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff files, Staff 1 (S1) did not have a completed health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Licensee agrees to have a completed health screening completed and documented for Staff 1 (S1) and to submit proof to LPA by the POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident files, Resident 1 (R1) did not have a completed pre-appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Licensee agrees to complete a pre-appraisal for R1 by the POC due date and to submit proof to the LPA by the 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/28/2026 04:59 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 04/28/2026 at 04:34 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: LAGUNA SENIOR LIVING LLC
FACILITY NUMBER: 306006637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident files, Resident 1
(R1) did not have a completed reappraisal/care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Licensee agrees to complete a appraisal/care plan for Resident 1 (R1) by the POC due date and to submit the appraisal/care plan to the LPA.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Resident 1 (R1) has bed rails and does not a doctor's orders for bed rails in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Licensee agrees to remove the bed rails or to obtain a doctor's order for bed rails. Licensee to submit proof of correction to the LPA by the 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2026


LIC809 (FAS) - (06/04)
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