306005765-5-12-2025-22-AS-KSGH-DGLR7X-20250512124705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005765
Report Date: 05/12/2025
Date Signed: 05/12/2025 12:47:48 PM

Document Has Been Signed on 05/12/2025 12:47 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:	NORA'S PLACE 1		FACILITY NUMBER:	306005765
ADMINISTRATOR/ DIRECTOR:	AVENDANO, REINER		FACILITY TYPE:	740
ADDRESS:	25612 ADRIANA STREET		TELEPHONE:	(949) 273-9951
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	05/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Mark Cruz, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:50 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after after introducing himself and stating the purpose of the visit. Administrator Mark Ryan Cruz was notified of the visit via telephone and arrived later to assist. There are currently five residents in care, three of which are receiving hospice care at this time out of an authorized hospice waiver capacity of four residents. LPA observed residents relaxing in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with a detached garage. The facility has four private and one shared bedrooms along with one staff room that is verified to be locked. There are two shared bathrooms throughout the facility, one of which designated for use by staff, as well as one en-suite bathroom in the shared bedroom. Bedrooms appear clean and sanitary. Some of the residents are using half rails or full rails for postural supports. Adequate orders present in all files or hospice plans of care reviewed. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Hot water temperature measured at 110F in two bathrooms with faucets used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secured. CONTINUED ON FORM LIC809-C

Sheila Santos	TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: NORA'S PLACE 1	FACILITY NUMBER: 306005765
	VISIT DATE: 05/12/2025

NARRATIVE

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CONTINUED FROM LIC809
The mounted fire extinguisher is charged, with up-to-date maintenance tag attached. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The garage is inaccessible to residents and used for laundry as well as additional storage of food and supplies.

LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. There are self-latching gates on both sides of the property and the routes of egress are free of clutter and obstructions. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress.

LPA reviewed five resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Oxygen is currently in use with adequate signs posted. There are no residents currently assessed as being bedridden at the time of the visit. Five resident interviews were attempted or conducted during the visit along with staff interviews.

LPA reviewed staff records for the three caregivers present during the visit. All staff members listed on the roster form LIC500 are background cleared and associated to the licensed location accurately. Present staff members have current CPR certificates on file. 2025 annual training provided. Disaster drills are conducted quarterly with proof of attendance provided.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report were provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

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