306001028-6-29-2026-22-AS-JALE-DVHQDF-20260629120439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001028
Report Date: 06/29/2026
Date Signed: 06/29/2026 12:05:08 PM

Document Has Been Signed on 06/29/2026 12:05 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:	GOOD SAMARITAN II		FACILITY NUMBER:	306001028
ADMINISTRATOR/ DIRECTOR:	CAMBIO, SUSAN & LEO		FACILITY TYPE:	740
ADDRESS:	26852 LA SIERRA		TELEPHONE:	(949) 367-1228
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	06/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Leonardo Cambio, Susan Cambio		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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	Licensing Program Analysts (LPAs) made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry. LPAs met with Administrators, Leonardo Cambio and Susan Cambio explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, no bed-ridden. Facility is a 2 level home with 5 bedrooms, 2 bathrooms, kitchen, great room with a dining room table and a living room with a screened fireplace. The second level is a loft. Residents are not allowed in loft. Administrator Leonardo Cambio certificate expires August 9, 2027. LPAs and administrator toured facility. LPAs toured resident rooms 1 resident room is private and two rooms are shared. All resident rooms had the required furnishings and bed linens. Extra linens and towels are stored in the hall closet. Smoke detectors/ carbon monoxide tested operational. Fire extinguisher in hallway is fully charged. The last emergency drill was conducted on March 7, 2026. LPAs and administrator toured garage, which is locked and used for storage. LPAs observed extra food, supplies and furniture stored in garage. LPAs observed both bathrooms are clean and operational. Hot water measured 112.2 degrees Fahrenheit. LPAs and administrator toured backyard, there were no bodies of water. LPAs observed shaded seating areas for clients to sit outside. No obstacles or hazards observed in the backyard. Both exit gates are operational. LPAs and administrator inspected the kitchen. LPAs observed knives and sharp objects are kept locked in kitchen cabinet. LPAs observed medications are kept locked in the kitchen drawer. The stove has knobs removed for residents safety. LPAs observed two days perishable and 7 days non perishable food supply on hand. LPAs observed three day emergency supply of food and water. LPAs inspected the first aid kit. First aid kit did not have a first aid manual. LPAs inspected the loft, the loft is used for staff only. LPAs observed the light fixture on the ceiling in the loft did not have a cover. LPAs did not observe an emergency evacuation chair. LPAs reviewed two staff files, no discrepancies observed. All staff had required training and CPR/ First Aid training. All staff members are background cleared and associated to facility.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026

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: GOOD SAMARITAN II	FACILITY NUMBER: 306001028
	VISIT DATE: 06/29/2026

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LPAs reviewed six resident files and two resident medications, no discrepancies observed. Facility does not have a dedicated internet device for resident use.

No deficiencies are being cited as a result of this visit. Technical violations are being issued. Please see LIC9102s dated June 29, 2026. An exit interview was conducted with the facility administrator and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026

LIC809 (FAS) - (06/04)

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