306005504-1-27-2026-22-AS-WVAS-DQQSJ4-20260127125432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005504
Report Date: 01/27/2026
Date Signed: 01/27/2026 12:54:41 PM

Document Has Been Signed on 01/27/2026 12:54 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:	OUR LADY OF GUADALUPE HOME		FACILITY NUMBER:	306005504
ADMINISTRATOR/ DIRECTOR:	CRESENCIA D. SANTIAGO		FACILITY TYPE:	735
ADDRESS:	24361 BRIDGER RD		TELEPHONE:	(949) 328-9784
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	01/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Cresencia Santiago (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE

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On Today's date January 27, 2026 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by facility staff. LPA explained the purpose for the visit, and Administrator (AD) Cresencia Santiago was notified via telephone and later arrived to assist with the inspection. LPA observed Cresencia Santiago has a valid Administrator certificate which expires on September 17, 2027. LPA Vanegas began a tour of the facility and observed the following. The facility is a single-story home with five bedrooms four of which are for client use, and one of which is a staff room, two shared client bathrooms, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage.

LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed one client in care and two facility staff present. LPA inspected the four client bedrooms, and they were observed to be free of any hazards. LPA observed the client bedrooms had the required furnishings such as a bed, a chair, a chest of drawers, a reading lamp, and enough storage space to store personal belongings. All client beds had clean linens in good repair; meaning no strains or tares. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared client bathrooms. Resident bathrooms are clean and free of mildew and debris. Faucets and toilets were operational. Hot water temperature measured between 116.0 and 116.7 degrees Fahrenheit. LPA observed the facility has a sufficient amount of emergency food and water stored in a hallway closet.

LPA observed the kitchen to be clean and free of any mildew and debris. LPA Vanegas observed there to be a two day perishable and seven day nonperishable food supply on hand. LPA observed a gas stove, microwave, dishwasher, refrigerator, washer, and dryer to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies and medications to be locked away and inaccessible to clients in care CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

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: OUR LADY OF GUADALUPE HOME	FACILITY NUMBER: 306005504
	VISIT DATE: 01/27/2026

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A fire extinguisher is located in a the kitchen, and it was observed the be charged and purchased on July 02, 2025. LPA tested the wired smoke detector and carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 26, 2025. LPA Vanegas reviewed P&I with AD, per LPA review all balances are documented correctly and are up to date.

LPA Vanegas reviewed three staff files, and four resident files. All resident files had all required documents. All staff records had annual training completed and filed correctly. However one staff out of three did not have an updated CPR/First aid training documented. A deficiency will be issued on today's date. LPA Vanegas reviewed medication administration record, and medications for all four clients. Per LPA review medications are being administered per physicians orders and no discrepancies were found.

LPA Vanegas conducted a tour of the outside of the facility and observed the following. LPA observed the outside of the facility to have a large backyard, no obstructions or hazards were observed along the exit routers. LPA observed a shaded seating area, and the side gates to be unlocked and self latching. LPA observed the backyard to be large enough to participate in outdoor activities upon client request.

Based on observations made during today's visit deficiencies will be issued per title 22 division 6 of the California Code of Regulations. An exit interview was conducted with AD Crisencia Santiago, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2026 12:54 PM - It Cannot Be Edited

Created By: William Vanegas On 01/27/2026 at 12:44 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: OUR LADY OF GUADALUPE HOME	FACILITY NUMBER: 306005504
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85165(f)(7)

Emergency Intervention Staff Training

(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one out of three staff did not have a valid CPR/First aid certificate in their personale file or had it ready for review which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/03/2026
	Plan of Correction
1 2 3 4	Administrator agrees to complete first aid and CPR training by the POC due date, and will send proof of correction to LPA via email.

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.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026

LIC809 (FAS) - (06/04)

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