<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005160
Report Date: 06/19/2024
Date Signed: 06/19/2024 05:48:09 PM


Document Has Been Signed on 06/19/2024 05:48 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:PACIFIC SHORES OF MISSION VIEJOFACILITY NUMBER:
306005160
ADMINISTRATOR:ZUEHL HERMINIA AMYFACILITY TYPE:
740
ADDRESS:24741 ACROPOLIS DRIVETELEPHONE:
(949) 683-8736
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Herminia Zuehl- Administrator
Benigno Bulanadi- Administrator		TIME COMPLETED:
06:00 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) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA Cho was greeted and granted entry by Administrator (Admin) Benigno Bulanadi. Licensee/Administrator Herminia Zuehl arrived shortly.

The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory in which one (1) may be bedridden and maintains a hospice waiver for six (6). There is one (1) bedridden resident and three (3) residents under hospice care on today's date.

LPA toured the interior and exterior portions of the facility. There are a total of five resident bedrooms and one resident bathroom. There is one staff bedroom and bathroom. LPA observed the facility to be clean, sanitary, and operational. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed resident bathroom to be in good repair, provided with handrails, and a non-skid floor mat. The hot water temperature measured at 109.4 degrees Fahrenheit in the resident bathroom and 112.4 in the staff/guest bathroom. Facility met the two day perishable and seven day non-perishable food supplies. LPA observed medications, toxins, and sharps were inaccessible to the residents. The fire extinguisher was serviced on April 14, 2024. LPA observed clutter in the garage which is a safety hazard and administrators were advised to clear the clutter. For the exterior portion, facility had sufficient seating and shading. The exit doors were self-closing and self-latching. LPA observed the emergency disaster supplies including food/water. LPA observed the required "See Something, Say Something' (PUB475) poster in the required size. Administrator's Certificate for Beningno Bulanadi expires on July 17, 2025.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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


Document Has Been Signed on 06/19/2024 05:48 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: PACIFIC SHORES OF MISSION VIEJO
FACILITY NUMBER: 306005160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed clutter and was unable to walk through the garage which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
1
2
3
4
Administrator stated that they will clean the clutter in the garage and to submit a photograph to LPA via email by POC due date.
Type B
Section Cited
CCR
87458(b)(1)
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and record review, facility did not obtain TB test result for R1 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Administrator stated that proof of TB test results for R1 will be submitted to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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: PACIFIC SHORES OF MISSION VIEJO
FACILITY NUMBER: 306005160
VISIT DATE: 06/19/2024
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
26
27
28
29
30
31
32
LPA conducted an audit of six residents' files and two staff files. A discrepancy was observed with one resident file as no proof of TB testing was provided for Resident #1 (R1). No discrepancies for the staff files. Resident interviews were conducted however LPA could not meet with the caregivers as one staff was preparing dinner while the other was assisting residents. Medications were audited. No discrepancies noted.

LPA consulted the following: to clear the clutter in the garage in order to adhere to the regulations by the State Fire Marshal, to obtain a Tuberculosis test result for R1, and to pay the annual licensing fee that was due on June 10, 2024.

Based on the observations made during today's visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See the attached LIC9099D.

An exit interview was conducted with Administrators Herminia Zuehl and Beningo Bulanadi, and a copy of this report including the LIC809C, LIC809D, LIC811s, and the appeal rights were provided during this visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3