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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005295
Report Date: 07/29/2025
Date Signed: 07/29/2025 10:38:05 AM

Document Has Been Signed on 07/29/2025 10:38 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:MAE HOUSEFACILITY NUMBER:
306005295
ADMINISTRATOR/
DIRECTOR:		MAI, ANNIEFACILITY TYPE:
735
ADDRESS:521 FULLERTON AVETELEPHONE:
(714) 478-5557
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92663
CAPACITY: 4CENSUS: 4DATE:
07/29/2025
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Megan Parrish, Administrator
Lizabeth Slater, licensee		TIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a scheduled case management visit with facility staff at the current licensed facility as well as a planned temporary location situated at 2870 Alanzo Lane, Costa Mesa, Ca 92626. LPA was first greeted by facility staff at the Alanzo Lane location and conducted a tour of the premises. Facility staff stated the intent to move into the Alanzo Lane location on September 19, 2025 in order for the current address to be remodeled in order to offer each of the four clients with a private bedroom. Upon completion of the remodel, facility staff intends to move back into the current address.

The planned relocation house is a one-level house with four private bedrooms and two bathrooms including one en-suite bath. All four bedrooms have storage space present. Both bathrooms are equipped with grab bars. Painting work is in progress and water temperature in the client's bathrooms could not be measured at this time. Licensee advised to verify water dispensed upon move-in is within the 105-120F range required by Title 22 regulations. A kitchen with a full-size refrigerator is observed, along with additional appliances and a range. There are self-latching gates on both routes of egress and no observed obstructions. There is a jacuzzi on the premises along with a fully fenced swimming pool. The fence is however stated to only measure four feet in height and will need to be replaced with securing measures as detailed in Section 80087(e)(1) of the California Code of Regulations.

CONTINUED ON FORM LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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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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: MAE HOUSE
FACILITY NUMBER: 306005295
VISIT DATE: 07/29/2025
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CONTINUED FROM LIC809
LPA then met facility staff at the current licensed location for the facility at 521 Fullerton Ave in Newport Beach. LPA verified the furniture that will be relocated upon move-in including a sofa and living room furniture, a dining table and chairs, a breakfast table and chairs, a small combined refrigerator, one bed, one dresser, one night stand and at least one lamp for each of the clients, the current washer and drier as well as outdoor furniture and an umbrella. The facility van and storage shelving will also be relocated upon move-in.

The relocation location for the facility is approved conditionally pending the described relocation of furniture and equipment, fire extinguishers and adequate fencing or covering of the bodies of water on the premises. Additionally, the 2870 Alanzo Lane location in Costa Mesa will need to obtain an adequate fire clearance prior to the anticipated move-in on September 19, 2025.

An exit interview was conducted and a copy of this report was provided to a facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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