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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003443
Report Date: 09/04/2026
Date Signed: 09/04/2026 01:47:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2026 01:47 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:ACTIVE SENIOR HOME CAREFACILITY NUMBER:
306003443
ADMINISTRATOR/
DIRECTOR:		BINTINTAN, AURICAFACILITY TYPE:
740
ADDRESS:26771 VIA VICTORIATELEPHONE:
(949) 380-1143
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Aurica Bintintan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection. LPA was greeted and granted entry by Caregiver Tedjo Pranoto. Administrator Aurica Bintintan arrived on premise to assist with the inspection. Administrator Aurica Bintintan has a valid certificate expiring March 25, 2028.

The following was observed during the inspection:
This is a single story residential home. Facility is approved for six non-ambulatory and maintains a hospice waiver for five. During today's visit, LPA observed five residents and two residents under hospice care. Facility is meeting the conditions and limitations specified on the license. LPA observed two caregivers on duty and verified fingerprint clearance and association statuses. LPA observed two private staff bedrooms, one private staff bathroom in the primary bedroom, four private resident bedrooms, one shared resident bedroom, and five resident bathrooms. All resident bedrooms have the required furnishings and ample lighting. The bathrooms are found to be in compliance equipped with grab bars and slip resistant mats. The hot water temperature measured at 110.0, 113.3, 115.2, 114.2, and 113.8 degrees Fahrenheit in the resident bathrooms. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway is free of hazard and obstruction. The two sheds in the passageway holds emergency disaster supplies, food, water, first aid, incontinence supplies, medical equipment, and cleaning solutions which are inaccessible to the residents. The two exit gates are operational, and there are sufficient seating and shading. The fire extinguisher was purchased on August 20, 2026.
Lourdes Montoya
Jessica Cho
DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2026
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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Document Has Been Signed on 09/04/2026 01:47 PM - It Cannot Be Edited


Created By: Jessica Cho On 09/04/2026 at 01:20 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: ACTIVE SENIOR HOME CARE
FACILITY NUMBER: 306003443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87465(c)(2)

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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Adminstrator and staff will receive medication training and will forward proof of training to LPA via email by POC due date.
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Based on observation and record review of two residents' medications, it was noted per the MAR that Quetiapine & Hydroxizine were administered for R2 when in fact the bubble packs were missing. This poses a potential Health, Safety, and/or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2026


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: ACTIVE SENIOR HOME CARE
FACILITY NUMBER: 306003443
VISIT DATE: 09/04/2026
NARRATIVE
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The auditory devices and dual functioning smoke/carbon monoxide detectors were tested and found operational. The facility is at a comfortable temperature range.

The Emergency Disaster Plan (LIC610E) was reviewed. Emergency supplies including food and water are stored in the shed. Disaster drills are conducted quarterly with the last date on July 24, 2026. LPA observed the Complaint Poster (PUB475) posted in the correct size in the entry way.

LPA audited six residents' and two personnel files in which no discrepancies were found. Medications were audited for two of six residents. Discrepancies found with administration and documentation for one of two residents' medications reviewed.

Based on the observations made during today's visit, a deficiency is being cited, and an advisory is being issued.

An exit interview was conducted with Administrator Aurica Bintintan, and a copy of this report including the appeal rights were provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC809 (FAS) - (06/04)
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