306006783-5-7-2026-22-AS-EBEY-DTUNP3-20260507103739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006783
Report Date: 05/07/2026
Date Signed: 05/07/2026 10:40:42 AM

Document Has Been Signed on 05/07/2026 10:40 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:	MI LUNA ASSISTED LIVING		FACILITY NUMBER:	306006783
ADMINISTRATOR/ DIRECTOR:	ATENCIO, EFRELYN		FACILITY TYPE:	740
ADDRESS:	9472 GRACKLE AVENUE		TELEPHONE:	(714) 253-2306
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 0	DATE:	05/07/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Jason Gettler, Applican and John Atencio, Consultant		TIME VISIT/ INSPECTION COMPLETED:	10:45 AM

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	On May 7, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived announced for the purpose of conducting the Pre-Licensing visit for an Initial Application. LPA conducted the visit with Applicant Jason Gettler and Consultant John Atencio. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on June 18, 2025, for age range 60 and older, with Fire Clearance approved for five (5) non-ambulatory residents and one (1) Bedridden resident in Room #5. The applicant stated there is a pending request for a Hospice waiver for six (6). LPA toured the facility's indoor and outdoor physical plant with Applicant Jason Gettler. The following were observed: Structure: The facility is a single-story property in a residential neighborhood comprised of five resident bedrooms, three full bathrooms, and an attached two car garage. The common areas include the living room, dining area, kitchen, and backyard were observed. LPA observed an ADU in the backyard that is not on the facility sketch and separate from the facility. Cameras were observed on the front door and in the following common areas: interior entry way, dining room/kitchen, and hallway. Telephone Number: The facility currently has a land line with the number (657)204-9240. CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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: MI LUNA ASSISTED LIVING	FACILITY NUMBER: 306006783
	VISIT DATE: 05/07/2026

NARRATIVE

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Emergency Phone Numbers/Exit Plan:
Posted in the entry way.

Postings:
The See Something, Say Something (PUB475) was posted in the correct size and all other required posting were available in the entry way.

Food Service and Menu:
Supply of seven-day non-perishable and two-day perishables were observed in the kitchen. The emergency food and water supply were also available. LPA observed the Activity Schedule and Food Menu posted.

Smoke and Carbon Monoxide Detectors:
The smoke detectors and carbon monoxide alert systems were tested and found operational.

Fire Extinguishers:
A fire extinguisher was mounted, fully charged, and purchased on October 10, 2025.

Fire Clearance:
Approved on October 13, 2025, for five (5) non-ambulatory residents and 1 Bedridden resident in Bedroom #5 only.

Signal System:
The facility does not signal system.

Bedrooms:
The resident bedrooms had all required components and accommodate the residents’ furnishings. All rooms and closets contained space for residents’ personal items and belongings.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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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: MI LUNA ASSISTED LIVING	FACILITY NUMBER: 306006783
	VISIT DATE: 05/07/2026

NARRATIVE

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Bathrooms:
Bathrooms were clean with grab bars were available near toilets and in showers, and slip mats were present.

Water Temperature:
The water temperature in the resident bathroom measured between 110.3 and 114.4 degrees Fahrenheit.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies for resident use were fully stocked.

Appliances:
Stove burners, microwave, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Medication:
Medication will be secured in a closet in the hallway.

Reading Material, Games, Equipment, & Materials:
Games and activities were available.

Sharps and Toxins:
Sharps will be secured in drawer in the kitchen and inaccessible. Cleaning supplies and toxins were observed locked under the sink.

Medications, First Aid Kit, & Manual:
The First Aid Kit was checked and contains all the required elements.

CONTINUE TO LIC809-C ..

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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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: MI LUNA ASSISTED LIVING	FACILITY NUMBER: 306006783
	VISIT DATE: 05/07/2026

NARRATIVE

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Liability Insurance and Surety Bond:
Facility does not have liability insurance for the new facility. A proposal for liability insurance protection was requested

Component III was waived by the applicant as their consultant present and available, fulfilling the requirements previously for existing facilities.

On today's visit, all items reviewed during this inspection are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with the above individuals, and a copy of this report was provided at the time of this visit.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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