306004687-8-7-2026-22-AS-JALE-DWQQRJ-20260807122400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004687
Report Date: 08/07/2026
Date Signed: 08/07/2026 12:24:17 PM

Document Has Been Signed on 08/07/2026 12:24 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:	ADRIANA'S SENIOR CARE LIVING		FACILITY NUMBER:	306004687
ADMINISTRATOR/ DIRECTOR:	RICHARD MENDOZA, JR.		FACILITY TYPE:	740
ADDRESS:	25392 ADRIANA STREET		TELEPHONE:	(949) 273-5625
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	08/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Kevin Mendoza		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with staff Kevin Mendoza and explained the reason for the visit. Facility is single story home with 6 bedrooms, 3 bathrooms, kitchen, great room with a screened fireplace and a two car garage. Facility is licensed for 6 non-ambulatory of which 6 can be bedridden. The Administrator's, Richard Mendoza Jr, certificate expires on June 12, 2028. LPA and staff toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the kitchen is clean and organized. The 5 burner gas stove top did could not light unassisted. LPA observed a 2-day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed knives are kept locked in a kitchen cabinet. LPA and staff toured the garage. LPA observed a 3 day supply of emergency food and water stored in the garage. The garage is kept locked and used for storage. LPA observed extra food and supplies stored in the garage. LPA observed all resident rooms have the required furnishings and bed linens. Smoke detectors/carbon monoxide detectors tested operational. The fire extinguisher in the kitchen is fully charged. LPA observed medications are kept locked in the hall closet. Hot water measured 131.3 degrees Fahrenheit in the shared bathroom between bedroom 1 and bedroom 2. LPA and staff toured the backyard. No bodies of water observed. There is a shaded seating area with a table with an umbrella and chairs for residents to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed 6 resident files and medications, no discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed. LPA inspected the first aid kit. The first aid kit has all the required elements. The last emergency drill was conducted on June 1, 2026. Deficiencies are being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided.

Sheila Santos
Joseph Alejandre
	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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 08/07/2026 12:24 PM - It Cannot Be Edited

Created By: Joseph Alejandre On 08/07/2026 at 12:09 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: ADRIANA'S SENIOR CARE LIVING	FACILITY NUMBER: 306004687
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, LPA measured the hot water at 131.3 degree Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2026
	Plan of Correction
1 2 3 4	Licensee agrees to adjust the hot water to measure between 120.0 and 105.0 degrees Fahrenheit.

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.

	Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:

	Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/07/2026 12:24 PM - It Cannot Be Edited

Created By: Joseph Alejandre On 08/07/2026 at 12:09 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: ADRIANA'S SENIOR CARE LIVING	FACILITY NUMBER: 306004687
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, LPA observed the 5 burner gas stove top could not light unassisted, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee agree to repair or replace the gas stove top so it can light unassisted. Licensee to forward proof of correction to LPA by the POC due date.

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.

	Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:

	Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC809 (FAS) - (06/04)

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