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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001297
Report Date: 04/15/2025
Date Signed: 04/15/2025 10:16:48 AM

Document Has Been Signed on 04/15/2025 10:16 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:DISTOR'S RESIDENTIAL CAREFACILITY NUMBER:
306001297
ADMINISTRATOR/
DIRECTOR:		LORI J. DISTORFACILITY TYPE:
735
ADDRESS:22845 WILLARD AVETELEPHONE:
(949) 472-2062
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Caregiver Pelagia SangerTIME VISIT/
INSPECTION COMPLETED:
10:32 AM
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On 4/15/25 at 8:05 AM, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Lori Cook was notified via telephone but could not arrive to assist with the inspection. LPA observed that Administrator Lori Cook has a valid Administrator certificate which expires on November 20, 2025.

The facility is an Adult Residential Facility (ARF) licensed for six ambulatory clients. The facility is a single story home with three client bedrooms, one of which is shared, one staff bedroom, two client bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by a care giving staff, conducted a tour of the interior portion of the facility. On today's visit, LPA observed two clients in care and one care giving staff present . Per the care giving staff, one client was away at their Day Program at the time of visit. LPA observed clients relaxing in their respective bedrooms and in the dining room. LPA inspected the three client bedrooms and they were observed to be free of hazards. Client bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Client linens and blankets were clean. LPA observed additional linens to be stored in a cabinet in the dining room. LPA inspected the two client bathrooms and they were observed to be clean. Client bathrooms were equipped with non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 105 and 105.2 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to clients in care.

LPA observed the facility has a two day perishable and seven day non-perishable food supply in the kitchen. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked cabinet. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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: DISTOR'S RESIDENTIAL CARE
FACILITY NUMBER: 306001297
VISIT DATE: 04/15/2025
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LPA observed a fire extinguisher to be mounted in the kitchen. The fire extinguisher was observed to be charged and serviced as of March 13, 2025. LPA tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on April 4, 2025.

The centrally stored medication is kept in a locked medication cart in the dining room. LPA observed a First Aid kit to be stored in the dining room and it had all the required components. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to clients in care. LPA observed the two car garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in the locked garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by a care giving staff, conducted a tour of the exterior portion of the facility. LPA observed the exterior to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for client use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all three client files. All the required documentation were present and current in the client files reviewed. LPA reviewed all three clients’ medication and medication records. LPA reviewed the Personal and Incidental funds (P&I) for all three clients. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on today's observations, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with an authorized facility representative and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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