306005717-4-28-2025-22-AS-BLOZ-DG6UMG-20250428154220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005717
Report Date: 04/28/2025
Date Signed: 04/28/2025 03:43:27 PM

Document Has Been Signed on 04/28/2025 03:43 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:	LEISURE LOVE HOME CARE		FACILITY NUMBER:	306005717
ADMINISTRATOR/ DIRECTOR:	DELA CRUZ, DENNIS S		FACILITY TYPE:	740
ADDRESS:	24362 FORDVIEW		TELEPHONE:	(949) 454-1623
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator Dennis DeLa Cruz		TIME VISIT/ INSPECTION COMPLETED:	03:57 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	On 4/28/25 at 1 PM, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by Adminstrator (AD) Dennis DeLa Cruz after explaining the purpose for today's visit. LPA observed that Administrator Dennis DeLa Cruz has a valid Administrator certificate which expires January 18, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents on the first floor, and has a hospice waiver for four. The facility is a two story home with three shared resident bedrooms on the first floor, two shared resident bathrooms on the first floor, a living room, a dining room, a kitchen, two staff bedrooms upstairs, one staff bathroom upstairs, and an attached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, one of which is on hospice, and three staff present. LPA observed residents relaxing in their respective bedrooms and in common areas. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the three shared resident bedrooms and they were observed to be free of hazards. LPA observed resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the two residents bathrooms and they were observed to be clear of hazards. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 113.5 and 114 degrees Fahrenheit. LPA observed the second story of the facility is for staff use only and is off limits to residents in care. CONTINUED ON 809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

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: LEISURE LOVE HOME CARE	FACILITY NUMBER: 306005717
	VISIT DATE: 04/28/2025

NARRATIVE

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LPA observed the kitchen has a two day perishable and a seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the four burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed a fire extinguisher to be mounted on the wall in the kitchen. The fire extinguisher was observed to be charged and up to date on service. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility does not keep a log of the emergency disaster drills it conducts.

LPA observed the centrally stored medication to be kept in a locked cabinet in the kitchen. LPA observed a First Aid Kit to be stored in a locked kitchen cabinet and it had all the required components. LPA observed a fireplace in the living room and it was observed to be adequately fenced and not in operation at time of visit. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates on the north side and west side of the facility to be self latching and can be opened in an evacuation. LPA observed a pool in the backyard. LPA observed the pool to be adequately fenced and kept locked for resident safety.

LPA reviewed all five resident files. LPA observed the facility did not have a Pre-Admission Agreement on file for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5. LPA observed the facility did not have a Reappraisal on file for Resident #3 and Resident #4. LPA observed the Reappraisals for Resident #1, Resident #2, and Resident #5 to be outdated. LPA reviewed residents' medication and medication records. LPA reviewed five staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited on the attached 809-Ds. An exit interview was conducted with Administrator Dennis DeLa Cruz. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2025 03:43 PM - It Cannot Be Edited

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: LEISURE LOVE HOME CARE	FACILITY NUMBER: 306005717
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility did not have a Pre-Admission Appraisal on file for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5.
	POC Due Date: 05/12/2025
	Plan of Correction
1 2 3 4	AD agreed to complete Pre-Admission Appraisals for all five residents. AD agreed to submit the Pre-Admission Appraisals to LPA via email or fax by POC date.

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the acility did not have a Reappraisal on file for Resident #3 and Resident #4. LPA oberved the Reappraisals for Resident #1, Resident #2, and Resident #5 were outdated.
	POC Due Date: 05/12/2025
	Plan of Correction
1 2 3 4	AD agreed to complete Reappraisals for all five residents. AD agreed to submit the Reappraisals to LPA via email or fax by POC date.

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	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2025 03:43 PM - It Cannot Be Edited

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: LEISURE LOVE HOME CARE	FACILITY NUMBER: 306005717
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the facility does not keep a log of the emergency disaster drills it conducts.
	POC Due Date: 05/12/2025
	Plan of Correction
1 2 3 4	AD agreed to conduct an emergency disaster drill with staff. AD agreed to submit proof of training to LPA via email or fax by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

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