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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005554
Report Date: 11/17/2025
Date Signed: 11/17/2025 02:23:16 PM

Document Has Been Signed on 11/17/2025 02:23 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:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR/
DIRECTOR:		KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 3DATE:
11/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:18 AM
MET WITH:Laura Palomino- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to follow up on a suicide attempt incident report involving Client #1 (C1) on November 1, 2025. LPA met with Administrator Laura Palomino and explained the purpose of the visit. On today's date, LPA conducted two staff interviews, inspected the medication, and obtained the following records: Face Sheet, Resident House Rules, Individual Program Plan (IPP), Client Development and Evaluation Report (CDER), Physician's Report, Health & Physical (H&P), Daily Progress Notes, Medication Administration Record (MAR) for November 2025, medication orders, Client Personal Property and Valuables, and Program Design.

C1 was admitted to the facility on October 16, 2025 and was placed on a 30-day trial ending on November 16, 2025. On November 1, 2025, approximately 5pm, C1 attempted suicide in their room by ingesting four bottles of medications that C1 had brought from their prior residence. C1 was immediately admitted to the hospital for treatment and was subsequently transferred to a second hospital on an involuntary psychiatric hold. C1 has not returned to the facility since.

Based on an interview with Admin Palomino, minimal information was obtained from C1's social worker and the regional center. The IPP and CDER was not current both dated October 24, 2023. Admin stated that they were not informed if C1 had other prior history of suicide attempts and was unaware per interview C1 having prior suicidal ideations which was documented on page 8 of the IPP. However, there were no documentation of prior suicide attempts per the CDER and IPP. Based on the review of the Program Design, page 15 indicates that when a client moves in, Admin stated that staff will walk through and inventory all personal belongings the day client moves in. Admin stated that facility was unaware that the four medications were in possession of C1.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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 11/17/2025 02:23 PM - It Cannot Be Edited


Created By: Jessica Cho On 11/17/2025 at 02:09 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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2025
Section Cited
CCR
85068.1(a)

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85068.1 Admission Procedures (a) The licensee shall develop, maintain, and implement admission procedures which shall meet the requirements specified in this section.
This requirement was not met as evidenced by:
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Administrator stated that they will review the Program Design including the Admission Procedure section and will submit an Acknowledgment of Understanding of the said deficiency to LPA by POC due date.
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Based on interviews and record review, facility did not follow the admission procedures which includes obtaining the current IPP and CDER which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.
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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:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
VISIT DATE: 11/17/2025
NARRATIVE
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It is determined based on the investigation that facility conducted their initial inventory check on C1's items, however facility did not obtain current documents of the CDER and IPP as noted on Section L, page 14 of the Admission Procedures.

Based on interviews and record review, a deficiency is being cited on the attached LIC809-D.

An exit interview was conducted with Administrator Laura Palomino, and copy of this report was provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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