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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005840
Report Date: 08/13/2026
Date Signed: 08/13/2026 03:41:48 PM

Document Has Been Signed on 08/13/2026 03:41 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NOTHING HILLS GUEST HOME LLCFACILITY NUMBER:
306005840
ADMINISTRATOR/
DIRECTOR:		MIRABUENO, MARIAFACILITY TYPE:
740
ADDRESS:13901 HEWES AVENUETELEPHONE:
(657) 267-0067
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 6DATE:
08/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Maria Pricilla Mirabueno - Licensee/Administrator TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit.
The facility is licensed for six non-ambulatory residents and has a hospice waiver for six. The facility is a single story home with four resident bedrooms, two of which are shared, three shared bathrooms, a living room, a dining room, a kitchen, a family room and an attached two car garage.
During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in resident bathrooms. The hot water temperature measured between 96.4 to 96.6 degrees Fahrenheit and all smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed unsecured scissors and unsecured lighter by facility stove. LPA observed emergency water in the family room and emergency food in cabinet in the hallway near room 1. Facility conducted an emergency drill on May 26, 2026.
LPA reviewed two out of two staff fingerprint records. Per interview with Staff 1 (S1) started working at the facility in January 2026 as a caregiver reliever for Monday and Tuesdays, per review of Guardian, S1 was not associated until May 23, 2026. Administrator has a current administrator certificate that expires on November 1, 2026.

Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report, appeal rights were provided to facility representative. An immediate civil penalty was issued.
Alisa Ortiz
Andrea Mendivil
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
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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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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Document Has Been Signed on 08/13/2026 03:41 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 08/13/2026 at 02:53 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: NOTHING HILLS GUEST HOME LLC
FACILITY NUMBER: 306005840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the cited above as there were scissors and a lighter unsecured in kitchen drawers. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/13/2026
Plan of Correction
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Corrected during visit
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and records reviewed the licensee did not comply with the cited above in 1 out of 2 staff members. Staff 1 was not assoicated to the facility prior to their employment in Janurary of 2026. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/13/2026
Plan of Correction
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Staff 1 was associated to the facility on May 23, 2026. Licensee will ensure all staff is associated prior to employment.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/13/2026 03:41 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 08/13/2026 at 03:00 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: NOTHING HILLS GUEST HOME LLC
FACILITY NUMBER: 306005840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observations the licensee did not comply with the cited above in three out of three bathrooms as the water temperature read at 96.4 to 96.6 degrees. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
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Staff adjusted water heater and will provide proof to LPA by poc due date that the temperature reads between 105 and 120 degrees
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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