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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006751
Report Date: 07/21/2025
Date Signed: 07/21/2025 12:54:50 PM

Document Has Been Signed on 07/21/2025 12:54 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:LUXXYLIVE LLCFACILITY NUMBER:
306006751
ADMINISTRATOR/
DIRECTOR:		CUEVAS, VERONICA AMELIAFACILITY TYPE:
740
ADDRESS:5111 HARCUM LNTELEPHONE:
(714) 883-1332
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 6CENSUS: 0DATE:
07/21/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Facility Administrator - Veronica Cuevas
House Manager - Savvas Kudsi		TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an announced pre-licensing visit and was greeted and granted entry by Facility Administrators (AD) - Veronica Cuevas and House Manager (HM) - Savvas Kudsi. LPA Rodriguez observed the Administrator's Certificate for Veronica Cuevas 1/17/2027. For this visit, there are 0 residents in care.

LPA Rodriguez toured the facility with AD- Cuevas and HM- Savvas Kudsi.

Structure: Facility is a single level structure. On 5/1/2025, The Orange County Fire Authority granted a fire clearance for a capacity of 6 residents (which 6 may be non-ambulatory, 2 may be on hospice and 0 may be bedridden). There are a total of 6 bedrooms, which all are private resident rooms, and 1 room designated as a gym for resident use. There are a total of 3 bathrooms of which 2 are full bathrooms and 1 half bathroom. There is is a garage that is utilized as a storage space.

Bedrooms: All 6 bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 115.3 degrees Fahrenheit.

Linens and Hygiene Supplies: Adequate supply of linens is stored in the bedrooms and in the garage.

Posters, Emergency Phone Numbers, Exit Plan: The PUB475 "See Something, Say Something" and Long Term Care Ombudsman poster was posted at the entrance of the facility. Emergency disaster plan is posted at the entrance and is also located in the facility binder.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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 4
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: LUXXYLIVE LLC
FACILITY NUMBER: 306006751
VISIT DATE: 07/21/2025
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Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care and located in a kitchen drawer. Facility had back-up emergency food and water supply located in the garage and in the kitchen.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide detectors were tested and operational.

Alarms: There are auditory alarms located on each door and pool gate were all were tested and operational.

Fire Extinguisher: Fully charged, mounted, and located in the kitchen and in the hallways. Fire extinguishers were dated for 2025.

Appliances: Stove is a four-burner induction stove, and there is single oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the garage.

Toxins: Inaccessible to residents and located in a locked cabinet in the garage.

Medications, PPE First-Aid Kit and Manual: LPA Rodriguez observed that First Aid Kit had all the required components. Medications were locked in a cabinet located in the hallway. Facility had an adequate supply of PPE located in the garage.

Backyard: LPA Rodriguez observed that there are 2 exit gates in the backyard on one side, of which are self-closing and self-latching. LPA Rodriguez observed that there is a pool located in the backyard, however is closed off by a 6ft fence, along with an auditory alarm that was observed to be operational.

Resident and Staff Files: Records were kept in a locked cabinet located in the hallway.

Recreational Activities: The facility has activities that commensurate with plan of operation.



LPA Rodriguez reviewed the Component III with AD - Veronica Cuevas and HM - Savvas Kudsi.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: LUXXYLIVE LLC
FACILITY NUMBER: 306006751
VISIT DATE: 07/21/2025
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Per interviews, AD - Veronica Cuevas and HM - Savvas Kudsi stated that they are not planning to advertise for special dementia program for this facility as of this time.

Prelicensing visit and Component III are now complete.

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

LPA Rodriguez conducted an exit interview with AD - Veronica Cuevas and HM - Savvas Kudsi and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
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