306006743-10-1-2025-22-AS-GTAT-DM2QJZ-20251001121335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006743
Report Date: 10/01/2025
Date Signed: 10/01/2025 12:13:48 PM

Document Has Been Signed on 10/01/2025 12:13 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:	LA SIERRA COTTAGE		FACILITY NUMBER:	306006743
ADMINISTRATOR/ DIRECTOR:	MANIAGO, MARIE		FACILITY TYPE:	740
ADDRESS:	26885 LA SIERRA DRIVE		TELEPHONE:	(917) 386-5767
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS:	DATE:	10/01/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Applicant Marie Maniago		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Garlli Tat and Licensing Program Manager (LPM) Sheila Santos conducted an announced pre-licensing visit to the facility and was greeted and granted entry by applicant Marie Maniago. LPA reviewed the Administrator's Certificate that expires on June 6, 2027.

LPA toured the exterior and interior portion of the facility with Marie Maniago.

Facility is a two-level structure home. On July 10, 2025, The Orange County Fire Authority granted fire clearance for a capacity of six residents (one of which may be ambulatory, four of which may be non-ambulatory, one may be bedridden, and a request for hospice waiver for six has been submitted for review). There are a total of six bedrooms, four of which are private resident rooms, one shared resident bedroom, and one staff bedroom. There is a garage that is utilized for storage.

All bedrooms were provided with brand new furniture's, in good repair, clean linens, adequate storage space, and kept hazard free. The bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in residents' bathrooms were measured at 134 degrees Fahrenheit. Applicant will have the water heater tank inspected since the water is still hot even after several attempts of adjustments were made during the visit. LPA will test the water on the 2nd pre-licensing visit schedule.

Adequate supply of brand new linens are stored in the hallway. LPA observed the PUB475 "See Something, Say Something" poster posted by the front entrance. Emergency disaster plan is posted in the dining room. Facility met the minimum two days and seven-day non-perishable food supplies. Sharp items and knives were locked in the kitchen drawers. Facility had back-up emergency food and water supply located in the kitchen cabinet.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

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: LA SIERRA COTTAGE	FACILITY NUMBER: 306006743
	VISIT DATE: 10/01/2025

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Wired smoke and carbon monoxide detectors were tested and operational. All auditory exit alarms were tested and observed to be operational. Fire extinguisher was fully charged, mounted, located in the kitchen, and tagged for the date of April 8, 2025.

Stove is a four-burner induction stove, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage. All appliances were operational. Toxins were locked and inaccessible to residents underneath the kitchen sink.

LPA observed that First-Aid kit had all the required components. Medication cabinet was observed in the dining room area. Applicant will keep this locked at all times.

A body of water was observed in the backyard. A locked fence surrounds the pool area. There are two exit gates in the backyard, one of which is self-latching.

Brand new binders were observed and kept in a locked cabinet located in the hallway for resident and staff files. The facility has activities that commensurate with plan of operation.

LPA reviewed the Component III with applicant, Marie Maniago.

A 2nd Pre-licensing visit will be scheduled on October 7, 2025 for the following to be corrected:

Missing self-latching gate entrance on the right side facing the house.
Applicant to clear the left side yard to ensure the safety of the residents, LPA observed multiple canned paints and boxes.
Applicant will install a lock gate by the entrance of the small stairs going towards the staff room and office.
Applicant will have the water heater tank inspected since the water is still hot even after several attempts of adjustments were made during the visit. Water temperature was measured 134F degrees. LPA will test the water on the 2nd Pre-licensing visit.

LPA will provide copy of this report to Centralized Applications Bureau for review and final determination of the application.

LPA conducted an exit interview with Marie Maniago and a copy of this report was reviewed and provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC809 (FAS) - (06/04)

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