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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005848
Report Date: 10/14/2026
Date Signed: 10/14/2026 04:20:04 PM

Document Has Been Signed on 10/14/2026 04:20 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:GOLDEN AGE SENIOR HOMESFACILITY NUMBER:
306005848
ADMINISTRATOR/
DIRECTOR:		MICO, RICO G.FACILITY TYPE:
740
ADDRESS:24982 WILKES PLACETELEPHONE:
(562) 338-4099
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 5DATE:
10/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rico MicoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Rico Mico and explained the reason for the visit. Rico Mico's Administrator's Certificate expires on March 25, 2028. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for six (6). Facility is a two story home with five (5) resident rooms, four (4) bathrooms, living room, dining room with a fireplace, kitchen, storage room and a staff bedroom on the second floor and a garage. The garage is kept locked and used to store supplies. The garage has the washer and dryer. The storage room is in the garage. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry of the facility. LPA observed all the resident rooms had the required furnishings and bed linens. Extra linens are stored in the hall cabinet. LPA observed all bathrooms are operational. LPA observed small dirt and debris on the bathroom floors and the floor in the dining room. LPA observed Hot water measured 106.3 degrees Fahrenheit in bathroom two (2). LPA and Administrator toured the kitchen. LPA observed knives are kept locked in a kitchen drawer, cleaning supplies are kept locked under the kitchen sink. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. LPA observed the 5 burner gas stove lights unassisted. LPA observed the stove did not have the knobs removed or any safety device on the stove preventing access by residents. The fire extinguisher in the kitchen is fully charged. Smoke detectors and carbon monoxide detectors tested operational. The last emergency drill was conducted on July 1, 2026. All staff present at the facility are background cleared and associated to the facility. LPA reviewed 2 staff files. LPA observed Staff 1 and Staff 2 have CPR training and had 20 hours of annual training but did not have 8 hours of Dementia training or 4 hours of training on hospice care, postural supports and restricted health conditions. No other discrepancies observed. LPA reviewed 5 resident files and medication. LPA observed Resident 1, Resident 4 and Resident 5 did not have a physician's report (medical assessment) on file.
Sheila Santos
Joseph Alejandre
DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2026
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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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: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848
VISIT DATE: 10/14/2026
NARRATIVE
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No other discrepancies noted. LPA consulted with Administrator regarding reporting requirements. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/14/2026 04:20 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/14/2026 at 04:07 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: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA observed small dirt and debris on the bathroom floors and the floor in the dining room. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Licensee agrees to have the facility cleaned in the areas mentioned above by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, Staff 1 and Staff 2 did not have 8 hours of Dementia training or 4 hours of training on hospice care, postural supports and restricted health conditions, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2026
Plan of Correction
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Licensee agrees to train Staff 1 and Staff 2 on 8 hours of Dementia training or 4 hours of training on hospice care, postural supports and restricted health conditions. Licensee to submit proof of training to LPA by the POC due 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
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/14/2026 04:20 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 10/14/2026 at 04:07 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: GOLDEN AGE SENIOR HOMES
FACILITY NUMBER: 306005848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review)], the licensee did not comply with the section cited above in 3 out of 5 resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2026
Plan of Correction
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Licensee agrees to get a physician's report LIC 602A for Residents 1, 4 and 5 by the POC due date.
Type B
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
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Based on record review, the licensee did not comply with the section cited above, that last drill was conducted on July 1, 2026, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
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Licensee agrees to conduct an emergency drill by the POC due date and to submit proof of the drill to the LPA by the POC due date. Licensee agrees to conduct emergency drills quarterly at the facility.
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
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2026


LIC809 (FAS) - (06/04)
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