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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004247
Report Date: 08/05/2025
Date Signed: 08/05/2025 09:53:36 AM

Document Has Been Signed on 08/05/2025 09:53 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:VENTANA ARF - LA SIERRAFACILITY NUMBER:
306004247
ADMINISTRATOR/
DIRECTOR:		HECTOR OBARFACILITY TYPE:
735
ADDRESS:26911 LA SIERRA DRTELEPHONE:
(949) 916-0084
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:24 AM
MET WITH:Dempsey NicolasTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Martinez arrived at the facility unannounced for the purpose of conducting the annual required visit. LPA was greeted and granted entry by House Manager, Dempsey Nicolas and explained the nature of the visit.

The facility is a two story home with an attached garage. Facility is licensed to serve six (6) clients of which two (2) may be non-ambulatory. There are two clients in care during today's visit with three care staff on duty.

LPA toured the interior and exterior portion of the facility and observed the facility to be clean, sanitary, and operational. LPA inspected the kitchen and observed sufficient two day supply of perishables and seven day supply of non-perishable food. There is additional food supply in the spare refrigerator located in the garage. Medication is stored in a kitchen cabinet locked and inaccessible to clients in care. LPA inspected that medication was label and in its original packaging. First aid kit and book observed to be located with medication storage. The first floor consists of four bedrooms occupied by two clients and one staff. Two client bathrooms are also on the first floor. The clients' bedrooms were appropriately furnished and in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed, and clean linens were adequately stocked. LPA inspected bathrooms and were noted to be in compliance, clean and operational. The water temperature measured at 106.1 degrees Fahrenheit. The second floor consists of three rooms and one bath which is occupied by the staff. LPA observed the evacuation chair stored in a closet by the stairwell. The fireplace was screened. Toxins, disinfectants were locked underneath kitchen sink and in garage storage cabinet. LPA toured the exterior portion of the facility. LPA observed the outdoor

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: VENTANA ARF - LA SIERRA
FACILITY NUMBER: 306004247
VISIT DATE: 08/05/2025
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passageway free of obstruction. The exit gate was operating. The swimming pool gate was at least 5 feet high and the gate latch self-closes and self-latches. LPA observed gate locks and surrounds the whole pool area. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers which were mounted, charged, and serviced on May 18, 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency disaster supplies including food/water in the living room closet. The emergency evacuation drills are being conducted monthly. LPA observed the fire drill log and last fire drill conducted was July 19, 2025. A working facility telephone number is (949) 916-0084, and remains available. LPA began review of records. LPA reviewed two clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information with a due date of August 30, 2025.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.



An exit interview was conducted with House Manager Dempsey Nicolas, and a copy of this report was provided at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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