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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004791
Report Date: 09/02/2025
Date Signed: 09/02/2025 07:26:33 PM

Document Has Been Signed on 09/02/2025 07:26 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:LOS TIEMPOS SENIOR LIVING #3FACILITY NUMBER:
306004791
ADMINISTRATOR/
DIRECTOR:		FIGUEROA,LESLYFACILITY TYPE:
740
ADDRESS:10869 GOLDENEYE AVETELEPHONE:
(714) 928-7912
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
09/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Rosa FigueroaTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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On September 2, 2025, at 12:30pm, Licensing Program Analysts (LPAs) Jenifer Tirre and Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs were greeted and granted entry by Caregiver (CG) Janeth Meza and met with Administrator (AD) Rosa Figueroa and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory residents and have a hospice waiver for four (4) residents. The building is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, three (3) bathrooms,, a living room area, dining area, kitchen, an outdoor covered seating area, and an attached two car garage.

LPAs Tirre and Bentley toured inside and outside of the physical plant with AD Figueroa. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature measured at 106.1 degrees F to 108 degrees F in bathrooms used by residents in care. A comfortable temperature of 74 degrees F was maintained in the facility.

LPAs Tirre and Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills was last conducted on April 28, 2025 and conducted quarterly. First aid kit is maintained and contains all the necessary elements. CONTINUED ON 809C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2025
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.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/02/2025 07:26 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 09/02/2025 at 05:27 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: LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER: 306004791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
All individuals subject a criminal record review pursuant to H&S code section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) obtain a california clearance or criminal record exemption as required by the department

This requirement is not met as evidenced by: Staff 1 is not associated to facility Los Tiempos Senior Living #3- 306004791
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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Licensee to associate staff 1 and 2 to facility #306004791 by Plan of Correction (POC) due date September 3, 2025 and email proof to Department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Jenifer Tirre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2025 07:26 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 09/02/2025 at 05:47 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: LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER: 306004791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)(F)
Each resident's record shall contain at least the following information: (17) Documents and info required by the following (E) section 87463 reappraisals and (F) section 87505 documentation and support.

This requirement is not met as evidenced by: Four of six residents (R1,R2,R4 & R5) are missing reappraisal
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in four out of six persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Licensee to update Appraisals for R1, R2, R4 & R5 and submit proof to department by Plan of correction due date 9/9/2025.
Type B
Section Cited
HSC
1569.69(a)
Each residential care facility for the elderly licensed under this chapter shall that each employee of the facility who assists residents with the self administration of medications meets all the following training requirements.

This requirement is not met as evidenced by: three of five staff (S1, S2 & S3) are missing required medication training.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of five persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Licensee to provide proof of medication training to department by plan of correction due date 9/9/2025.
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:
Jenifer Tirre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


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: LOS TIEMPOS SENIOR LIVING #3
FACILITY NUMBER: 306004791
VISIT DATE: 09/02/2025
NARRATIVE
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During the visit, LPAs Tirre and Bentley observed the facility's all mandated posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-964-6310) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged and serviced on July 9, 2025. Liability Insurance is effective 6/26/2025 and expires on 6/26/2026.

LPAs Tirre and Bentley conducted an audit of six (6) resident files (R1-R6), five (5) staff files (S1-S5), and medication and medication administration review. LPAs Tirre and Bentley conducted two (2) staff interview and two (2) resident interviews.

The following Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, LIC 809 D, LIC811, Civil Penalty, a copy of this report and appeal rights were provided to Administrator Rosa Figueroa.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
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