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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002817
Report Date: 07/02/2025
Date Signed: 07/02/2025 02:28:00 PM

Document Has Been Signed on 07/02/2025 02:28 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:GLORIOUS HOME #2FACILITY NUMBER:
306002817
ADMINISTRATOR/
DIRECTOR:		JEAN-PIERRE DELAGNEAUFACILITY TYPE:
740
ADDRESS:24672 ARGUS DRIVETELEPHONE:
(949) 916-2079
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jean-Pierre Delagneau, licenseeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Jean-Pierre Delagneau was notified of the visit via telephone and arrived later to assist.

There are currently four residents in care, two of which are receiving hospice care at this time. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage, with four private bedrooms, one shared bedroom and two shared bathrooms.

Bedrooms appear clean and sanitary. There are three residents requiring the use of half rails for postural supports at the time of the visit. Hospice plans of care reviewed for the relevant residents. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 109F and 110F in two separate bathrooms equipped with faucets used for personal grooming.

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secured. Medication belonging to a staff member is however observed to have been left on the dresser in one of the bedrooms. Type B citation issued.

CONTINUED ON FORM LIC809-C
Sheila SantosTELEPHONE: (714) 334-2062
Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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.

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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: GLORIOUS HOME #2
FACILITY NUMBER: 306002817
VISIT DATE: 07/02/2025
NARRATIVE
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CONTINUED FROM LIC809
Fire extinguisher present is charged with up-to-date maintenance tag. Smoke detectors were found to be operational. Carbon monoxide detector found to have an inoperant battery that was replaced during the visit. Type A citation issued and cleared. The garage is secured and used for the storage of supplies and food. Laundry room and cleaning supplies are secured. Emergency food and water supplies verified to be present.

LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. The identified route of egress is free of clutter and obstructions. There are no bodies of water on the premises. Gardening equipment observed not to be secured. Type B citation issued. Egress alarms are in use on exit doors, however facility does not utilize locked perimeters or delayed egress.

LPA reviewed four resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. One resident is observed to have been assessed as bedridden upon admission but is currently able to reposition and attends meals and activities in the common living areas. Type B citation issued as the change in condition has not been documented at this time. Consultation provided on updated requirements for medical assessments and copy of the updated physician report LIC602a provided. Resident interviews were conducted or attempted during the visit along with staff interviews.

LPA reviewed staff records for three staff members present during the visit. CPR training, initial and annual training reviewed for 2024 and 2025. Disaster drills are conducted quarterly and documented. Staff members are verified to be background cleared and associated to the licensed location. Administrator certificate is pending, consultation provided. The governing body appears to be inactive per Secretary of State records, consultation provided.

Based on the observation conducted during the present visit, one type A deficiency and 5 type B deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 02:28 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/02/2025 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #2
FACILITY NUMBER: 306002817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the carbon monoxide detector observed in the facility's kitchen is found to be non-operational at the time of the visit. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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The battery for the detector was replaced during the visit. Deficiency cleared.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (714) 497-8754
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 02:28 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/02/2025 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #2
FACILITY NUMBER: 306002817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87309(c)
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation made during the visit, the licensee did not comply with the section cited above as medication and supplements belonging to a staff member were observed to have been left on a resident's dresser which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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Medication placed in secure storage in the locked laundry room.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (714) 497-8754
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 02:28 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/02/2025 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #2
FACILITY NUMBER: 306002817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(i)
Planned Activities
(i) The licensee shall implement reasonable interventions in order to ensure the safety of all residents utilizing indoor and outdoor areas and take precautions to prevent residents from unsafe wandering and elopement, as defined in Section 87101, Definitions. Such precautions may not conflict with residents' personal rights as specified in Section 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as gardening equipment which can pose safety issues for residents was observed to be accessible in the facility's backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee to place the dangerous items in secure storage and provide proof to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87463(b)
Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as one resident is found to be assessed as bedridden in spite of their ability to attend meals and activities in a wheelchair in the common areas. This discrepancy in documented condition poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will obtain an updated medical assessment from the resident's primary care provider in order to have adequate documentation of the resident's present condition which is no longer bedridden.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (714) 497-8754
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 02:28 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/02/2025 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GLORIOUS HOME #2
FACILITY NUMBER: 306002817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as there is no signage in use in spite of one resident using PRN oxygen on the premises. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee to obtain an Oxygen in use sign which will be posted in the facility.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (714) 497-8754
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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