306005657-1-10-2025-22-AS-MTEA-DCSTWY-20250110140620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005657
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:06:49 PM

Document Has Been Signed on 01/10/2025 02:06 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:	PACIFICA HOME CARE LLC		FACILITY NUMBER:	306005657
ADMINISTRATOR/ DIRECTOR:	LUCERO, LUIS		FACILITY TYPE:	740
ADDRESS:	23711 VIA LA CORUNA		TELEPHONE:	(949) 874-8777
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:46 AM
MET WITH:	Luis Lucero and Jeffrey Gardner		TIME VISIT/ INSPECTION COMPLETED:	02:21 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:46 AM, LPA Tea was greeted and granted entry into the facility by caregiver staff, Jibran Pina and explained the reason for the visit. Administrators (AD) Luis Lucero and Jeffrey Gardner arrived shortly to assist with the visit. Facility is licensed for 6 non-ambulatory residents, of which 1 may be bedridden in bedroom #4, with a hospice waiver for two. Currently there are five residents during today's visit.

At 9:15 AM, LPA Tea reviewed five resident files and three staff files. Resident files contained all required documentation. Staff files had some discrepancies. AD Lucero’s certificate expires on July 18, 2025 and AD Gardner’s certificate expires on December 04, 2025.

LPA Tea along with AD Gardener toured the facility at 10:07 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 4 resident bedrooms, which one is shared, 2 full bathrooms, living room, dining room, and kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. During the tour a few toxins and medications were left unsecured, and staff immediately safely secured the products. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 117.3 F degrees and 113.5 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, dressing, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a locked box on the kitchen counter. LPA observed toxin substances to be secured and locked and inaccessible to clients under the kitchen sink and garage.

Annual Inspection continued on LIC809-C

Alisa Ortiz	TELEPHONE: (714) 287-4084
Michael Tea	TELEPHONE: 714-703-2840
	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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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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: PACIFICA HOME CARE LLC	FACILITY NUMBER: 306005657
	VISIT DATE: 01/10/2025

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Fire extinguishers are fully charged. The facility’s last fire drill was conducted on December 14, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gates are self-latching and operational on both sides of the facility. LPA observed emergency food and water supply in the garage. Facility provides activities based on their preferences and physical limitations such as walking, playing with cards, and doing karaoke. At the time of the visit residents were having meals together and lounging and watching TV in the living room.

At 10:39 AM LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with administrators Luis Lucero and Jeffrey Gardner and a copy of this report LIC809, 809-C, LIC858, LIC859, LIC9102TV was read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC809 (FAS) - (06/04)

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