306005986-5-18-2026-22-AS-RMAZ-DU7PYW-20260518114437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 05/18/2026
Date Signed: 05/18/2026 11:44:41 AM

Document Has Been Signed on 05/18/2026 11:44 AM - 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:	ACTIVCARE LAGUNA HILLS		FACILITY NUMBER:	306005986
ADMINISTRATOR/ DIRECTOR:	MILLER, PATRICIA		FACILITY TYPE:	740
ADDRESS:	25200 PASEO DE ALICIA		TELEPHONE:	(858) 565-4424
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY: 72		CENSUS: 61	DATE:	05/18/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Patricia Miller		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	This unannounced case management visit is being conducted by Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen to follow up on incident reported to Community Care Licensing. LPAs met with Patricia Miller, Executive Director and explained the nature of the visit. Incident report dated 5/1/26 for a witnessed fall involving resident R1. R1 was in a common area of the facility when it was observed R1 fell cause of fall is unknown. Staff assisted R1 immediately and R1 was observed to be confused and did not recall how the fall occurred. R1 complained of pain in left side extremities. 911 was called immediately and sent out for further evaluation. R1 underwent surgery due to injury and was sent out to a skilled nursing. Upon today’s visit LPAs observed R1 arriving at the facility clean, groomed and in good spirit. R1 was re-assessed prior to return to facility and was determined they needed a higher level of care, moved to another wing of the facility and required 1:1 care. R1 upon admissions was determined to be a fall risk resident and fall prevention measure were implemented. LPAs toured the facility and R1’s bedroom and did not observe any concerns with the bedroom. LPAs obtained copies of pertinent documents. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observation made during today's visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Executive Director and a copy of this LIC809 report was provided and left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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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