306005614-6-6-2025-22-AS-CROZ-DHDQLZ-20250606121645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005614
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:17:12 PM

Document Has Been Signed on 06/06/2025 12:17 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:	OASIS, THE		FACILITY NUMBER:	306005614
ADMINISTRATOR/ DIRECTOR:	PEREZ, JENNIFER		FACILITY TYPE:	740
ADDRESS:	24741 PENFIELD ST		TELEPHONE:	(949) 454-1503
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	06/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	House Manager - Efrain Matheus		TIME VISIT/ INSPECTION COMPLETED:	12:37 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) Celine Rodriguez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. For this visit, there are 6 residents in care, of which 3 are on hospice. For this visit, LPA Rodriguez met with house manager (S1) Efrain Matheus. LPA Rodriguez observed the facility administrator (AD) certificate for Hermelinda Perez which expires on 10/30/2026. LPA Rodriguez observed that the PUB475 "See Something, Say Something" poster was posted at the entrance of the facility. The facility has a total of 6 bedrooms, of which all 6 are private resident rooms. LPA Rodriguez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Facility was observed to have 3 bathrooms, of which 2 are located inside the facility, and 1 outside, however it was verified that the bathroom located outside is not for resident use. Bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Hot water was measured at 112.3 degrees Fahrenheit. LPA Rodriguez observed that the facility had a two-day supply of perishables and a seven-day supply of non-perishable food. LPA Rodriguez observed hallways were free of obstructions.

Sheila Santos	TELEPHONE: (714) 334-2062
Celine Rodriguez	TELEPHONE: 714-703-2840
	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

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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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: OASIS, THE	FACILITY NUMBER: 306005614
	VISIT DATE: 06/06/2025

NARRATIVE

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For the exterior portion, LPA Rodriguez observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. LPA Rodriguez observed that there is a body of water located in the backyard, however it is secured by a locked gate.

LPA Rodriguez observed that the facility has fire extinguishers that were charged, mounted and located in the kitchen with a maintenance tag dated for 2025. Sharp items, and medications were observed to be locked and inaccessible to residents in care. Cleaning supplies were observed to be locked in the garage and laundry room. LPA Rodriguez observed the Emergency and Disaster Plan posted in the facility binder which is located at the facility entrance, and that the facility has emergency supplies located in the garage.

LPA Rodriguez reviewed all six resident files. LPA Rodriguez reviewed staff files, and observed that current staff members are cleared and associated to the facility.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

An exit interview was conducted with S1 Matheus.

A copy of this report was explained and provided during the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine Rodriguez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025

LIC809 (FAS) - (06/04)

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