306005407-6-30-2026-22-AS-RMRT-DVJPYV-20260630114433

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005407
Report Date: 06/30/2026
Date Signed: 06/30/2026 11:44:52 AM

Document Has Been Signed on 06/30/2026 11:44 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:	MAISON FOR MOM		FACILITY NUMBER:	306005407
ADMINISTRATOR/ DIRECTOR:	LUDINOT NIC, YAMASHIRO SHE		FACILITY TYPE:	740
ADDRESS:	804 W BRENTWOOD AVENUE		TELEPHONE:	(310) 994-9181
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY: 6		CENSUS: 6	DATE:	06/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Shelly Yamashiro, Laura Oudinot, Administrators and Joyce Cornejo, House Manager		TIME VISIT/ INSPECTION COMPLETED:	12:00 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) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by staff at 8am and met with House Manager (HM) Joyce Cornejo. LPA explained the purpose of the visit. Both Administrators Laura Oudinot and Shelly Yamashiro arrived at 8:30 to 9am but were unable stay the entire visit. The facility is a five bedroom, two bathroom single story home with an approved fire clearance of six non-ambulatory residents and a hospice waiver for six. Currently there are six residents in care with two residents on hospice. The garage has been recently converted to an additional dwelling unit with a separate address of 802 W. Brentwood Avenue and was permitted by the city in April 2026. During today's visit, LPA toured the physical plant and observed two residents reclining in the living room. The living room fireplace has protective mesh. There are two refrigerators in the kitchen and the facility retained a minimum of two days perishable food items and seven days of non perishable food items. The fire extinguishers was charged and were tested on September 16, 2025. The smoke and carbon monoxide detectors were inspected and tested and detectors were operational. The last fire drill was conducted on June 1, 2026. The facility temperature was 76 degrees Fahrenheit. LPA tested two of two bathrooms and the hot water temperatures ranged from 105.0 to 105.2 degrees Fahrenheit. Chlorox and cleaning supplies were observed in the first bathroom and a citation will be given. LPA toured resident bedrooms and all rooms had the required linens and furniture. No medications were observed in resident rooms and centrally stored medications were secured and reviewed. Per review, medications are being given as prescribed. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

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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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: MAISON FOR MOM	FACILITY NUMBER: 306005407
	VISIT DATE: 06/30/2026

NARRATIVE

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(Continued from LIC 809)

LPA toured the exterior of the property and observed one sliding door screen needed repair and a deficiency will be given. A shaded seating area was available for residents and pathways were clear of obstructions.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. One of six resident files needed an updated Medical Assessment which Administrators are working on obtaining. A deficiency will be cited. The certificate of liability insurance was current and will expire on July 31, 2026. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on October 6, 2027.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Joyce Cornejo, House Manager and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2026 11:44 AM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 06/30/2026 at 11:19 AM

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: MAISON FOR MOM	FACILITY NUMBER: 306005407
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in one of two resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2026
	Plan of Correction
1 2 3 4	Staff immediately removed the cleaning items and disposed of them in the trash can.

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.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2026 11:44 AM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 06/30/2026 at 11:19 AM

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: MAISON FOR MOM	FACILITY NUMBER: 306005407
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in one of one resident screen doors which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2026
	Plan of Correction
1 2 3 4	Administrator (AD) stated the handyman would be able to fix and repair the screen door within a week's time. AD will email LPA pictures of the repaired sliding screen door by POC due date.

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review and interview, the licensee did not comply with the section cited above in one of six resident files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2026
	Plan of Correction
1 2 3 4	Administrator (AD) will follow up with Primary Care Provider for Medical Assessment by POC due date. AD will email LPA the updated medical assessment.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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