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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005605
Report Date: 08/03/2026
Date Signed: 08/03/2026 12:40:48 PM

Document Has Been Signed on 08/03/2026 12:40 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:SOCAL EMPOWERED LLCFACILITY NUMBER:
306005605
ADMINISTRATOR/
DIRECTOR:		JAMES PERRAIEFACILITY TYPE:
772
ADDRESS:22602 COSTA BELLA DRTELEPHONE:
(949) 701-3551
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
08/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Assistant Clinical Director- Ashley SouthardTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On August 3, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Assistant Clinical Director Ashley Southard and explained the purpose of the visit.

The facility is licensed to operate for six (6) ambulatory clients. The facility is a two-story building located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) bathrooms, one office area, living area, dining area, art area, kitchen, and attached 3-car garage.

LPA toured the indoor and outdoor physical plant. There was shading and sufficient seating for the clients. LPA observed that the client bedrooms had all required elements with ample lighting. Showers, faucets, and toilets were sanitary and in operating condition. The hot water temperature measured between 141.9 degrees Fahrenheit to 144.6 degrees Fahrenheit in all client bathrooms. There was sufficient and clean supply of linens. LPA observed ample two-day supply of perishables and seven-day supply of non-perishables. LPA observed the emergency food, and emergency water stored in the garage. The carbon monoxide and smoke detectors were tested and operational. There are two (2) fire extinguisher that are securely mounted in kitchen and second floor hall that were inspected on June 22, 2026. Medications, sharps, and toxins were locked and inaccessible to the clients.

The following items were all posted and available for review: Emergency Disaster Plan (LIC610D), food menu, and client rights. Evidence of liability insurance was effective October 20, 2025, to October 20, 2026. Emergency Drills are conducted monthly and last conducted on July 31, 2026.

Evaluation Report Continues on LIC 809-C
Lourdes Montoya
Edward Kim
DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2026
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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Document Has Been Signed on 08/03/2026 12:40 PM - It Cannot Be Edited


Created By: Edward Kim On 08/03/2026 at 12:17 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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306005605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited. LPA observed the client bathrooms water temperature measured between 141.9 degrees F to 144.6 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2026
Plan of Correction
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Licensee stated they will send proof through a video of each client sink bathroom to measure between 105 degrees F and 120 degrees F, and send also a water temperature log for each client bathroom sink every hour from August 3, 2026, 2:00 PM, to August 4, 2026, 2:00 PM, to CCLD via email to edward.kim@dss.ca.gov by POC due date August 4, 2026.
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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2026


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: SOCAL EMPOWERED LLC
FACILITY NUMBER: 306005605
VISIT DATE: 08/03/2026
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LPA reviewed six client files and five staff files during today's visit. LPA Kim conducted interviews with two residents and three staff.

A deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Client bathrooms hot water temperature measured between 141.9 degrees Fahrenheit to 144.6 degrees Fahrenheit.

An exit interview was conducted and a copy of this report was provided to Assistant Clinical Director Ashley Southard.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
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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