306003618-2-20-2025-22-AS-RMAZ-DE42F2-20250220162048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003618
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:21:15 PM

Document Has Been Signed on 02/20/2025 04:21 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:	NEIGHBORHOOD SUITES - COSTEAU		FACILITY NUMBER:	306003618
ADMINISTRATOR/ DIRECTOR:	OFELIA ANGELES		FACILITY TYPE:	740
ADDRESS:	25005 COSTEAU STREET		TELEPHONE:	(949) 290-6907
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Ofelia Angeles, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 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) Ruth Martinez and Hanna Gough are conducting this unannounced visit for the purpose of completing the annual required inspection. LPAs arrived at the facility and was greeted and granted entry by staff. LPAs met with Administrator (AD) Ofelia Angeles and explained the nature of the visit. There are three residents at the facility. LPAs accompanied with (AD) began the tour of the inside and outside of the facility. LPAs observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishable foods available. There is additional food storage in a spare refrigerator and pantry located in the garage. The facility is maintained at a comfortable temperature. LPAs inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPAs reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPAs inspected the bathroom and LPAs measured the hot water temperature between 111.7-119.6 degrees Fahrenheit. The bathrooms observed to have a supply of soap, toilet paper and paper towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPAs observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and in a locked storage cabinet located in the garage. The facility has an available clean supply of linens. LPAs inspected residents’ bedrooms. All bedrooms observed to have all required components and furnishings. Storage space is provided for residents in their bedrooms. Smoke detectors/ carbon monoxide were tested and found to be operational. Continued on LIC809-C

Armando J Lucero	TELEPHONE: (949) 430-1222
Ruth Martinez	TELEPHONE: (657) 285-1397
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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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Document Has Been Signed on 02/20/2025 04:21 PM - It Cannot Be Edited

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: NEIGHBORHOOD SUITES - COSTEAU	FACILITY NUMBER: 306003618
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(a)(13)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of two caregivers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2025
	Plan of Correction
1 2 3 4	LPAs observed administrator and caregiver leave the facility to go get fingerprinted and provided proof to LPAs upon return. LPAs observed caregiver leaving the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Armando J Lucero	TELEPHONE: (949) 430-1222
Ruth Martinez	TELEPHONE: (657) 285-1397
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: NEIGHBORHOOD SUITES - COSTEAU	FACILITY NUMBER: 306003618
	VISIT DATE: 02/20/2025

NARRATIVE

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LPAs toured the outside of the facility and observed outdoor passageways are free of obstructions. LPAs observed the pool gate has an entry door which opens away from the pool. The fence has a lock that requires a key at the gate for inaccessibility. LPAs measured the pool fence which measured 5ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPAs observed a fire extinguisher in the kitchen with a service date of January 02, 2025. The last fire drill conducted was on January 21,2025. LPAs began review of records. LPAs reviewed two resident records. All the required documentation was present and current in the residents’ files. LPAs reviewed two employee records which had all the required documentation. One out of two caregivers present did not have a criminal record clearance and are not associated to the facility.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies. Civil Penalties were assessed on this date.

This report was reviewed with Administrator and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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