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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005585
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:31:07 PM

Document Has Been Signed on 07/02/2025 04:31 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:VIVIDUS SENIOR LIVINGFACILITY NUMBER:
306005585
ADMINISTRATOR/
DIRECTOR:		SHARIFAN, BAABAKFACILITY TYPE:
740
ADDRESS:25131 VIA PORTOLATELEPHONE:
(949) 777-5369
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:04 PM
MET WITH:Baabak "Bobbi" SharifanTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Baabak "Bobbi" Sharifan and explained the reason for the visit. The Administrator's certificate expires on August 6, 2025. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and the Administrator toured the facility. Facility is a single story home with an attached 2 car garage with 5 bedrooms, 3 bathrooms, kitchen, dining room and a living room with a fireplace. LPA observed the fireplace is screened. The fire extinguisher in the kitchen is fully charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. There is 3 day emergency food and water supply in the kitchen. LPA observed knives are kept locked under the kitchen sink. LPA observed the medications are kept locked in a kitchen cabinet. LPA and Administrator toured the resident rooms. 4 of the resident rooms are private and one is shared. LPA observed all resident rooms are clean and organized. All resident rooms had the required furnishings and bed linens. LPA toured the garage. The garage is kept locked and used for storage of extra supplies and food. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all 3 bathrooms are clean and operational. Hot water measured 108.6 degrees Fahrenheit in all 3 bathrooms. LPA and staff toured the backyard. No bodies of water observed. There is a table with an umbrella and chairs for residents to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed 5 resident files. 1 out of 5 residents did not have a current appraisal/needs and service plan. Resident 1 (R1) did not have a current appraisal/needs and service plan. LPA reviewed 5 resident medications, no discrepancies observed. LPA reviewed 2 staff files. No discrepancies observed. LPA inspected first aid kit. The first aid kit has all the required elements. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. LPA consulted with Administrator concerning reporting requirements. An exit interviewed was conducted and a copy of the report along with appeal rights was provided.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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 07/02/2025 04:31 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/02/2025 at 03:57 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: VIVIDUS SENIOR LIVING
FACILITY NUMBER: 306005585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files, Resident 1 does not have did not have a current appraisal/needs and service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Licensee agrees to have a new appraisal/needs and service plan completed for Resident 1 by July 10, 2025. Licensee to forward proof of correction to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 714-705-6018
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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