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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006721
Report Date: 05/05/2026
Date Signed: 05/05/2026 11:54:50 AM

Document Has Been Signed on 05/05/2026 11:54 AM - 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:GRANNY'S PLACE #5FACILITY NUMBER:
306006721
ADMINISTRATOR/
DIRECTOR:		ARNETT, KIMBERLYFACILITY TYPE:
740
ADDRESS:24606 SATURNA DRIVETELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
05/05/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Michalle NesbittTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Samer Haddadin conducted an announced pre-licensing visit to the above-mentioned facility. Upon arrival, LPA Haddadin was greeted by Compliance Manager (CM) Michalle Nesbitt, who granted entry into the facility.
The facility is a single-story residence consisting of seven bedrooms and six restrooms. The facility also has a one-car garage. During the visit, LPA Haddadin conducted a comprehensive inspection of the physical plant, which included the interior and exterior portions of the facility. LPA Haddadin and the CM tested the kitchen appliances, and all appliances were observed to be operational. Smoke detectors were tested and found to be operational. Hot water temperatures were measured in both restrooms and ranged from 116.5 degrees Fahrenheit to 117.9 degrees Fahrenheit. A fire extinguisher was observed to be fully charged, with a last inspection date of April 8, 2026.
LPA Haddadin inspected the exterior of the facility and observed no bodies of water on the premises. Adequate outdoor space was available for residents’ activities. Emergency exits were observed to be clear and unobstructed.
Although no residents were currently in care, the facility’s food supply was reviewed, and a seven-day supply of nonperishable food items was available. Knives and other sharps were secured in a locked kitchen drawer. Chemicals and cleaning supplies were secured in a locked cabinet located in the laundry room next to the kitchen.
LPA Haddadin observed that the PUB 475 complaint poster was posted in the required 20-inch by 26-inch size.
{***CONTINUE809C***
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2026
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: GRANNY'S PLACE #5
FACILITY NUMBER: 306006721
VISIT DATE: 05/05/2026
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The first aid kit was inspected and contained the required components. Facility staff files were stored in a cabinet located in the kitchen. Medications were observed secured in the same cabinet and will be inaccessible to future residents.

Component III of the licensing process was conducted with Compliance Manager Michalle Nesbitt.

LPA Haddadin informed the Licensee that final licensure approval will be determined and issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was provided to the CM.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC809 (FAS) - (06/04)
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