306006036-10-28-2025-22-AS-BLOZ-DMVQBG-20251028120132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006036
Report Date: 10/28/2025
Date Signed: 10/28/2025 12:02:08 PM

Document Has Been Signed on 10/28/2025 12:02 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:	SOCAL EMPOWERED LLC		FACILITY NUMBER:	306006036
ADMINISTRATOR/ DIRECTOR:	PERRAIE, JAMES		FACILITY TYPE:	772
ADDRESS:	23671 BRASILIA		TELEPHONE:	(888) 630-3860
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 5	DATE:	10/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Program Director Susan Kue		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	On October 28, 2025, 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 staff after explaining the purpose for the visit. Program Director (PD) Susan Kue was notified via telephone and later arrived to assist with the inspection. The facility is a Social Rehabilitation Facility (SRF), Short Term Crisis Residential Program, licensed for six ambulatory clients. The facility is a two story residential home with three shared client bedrooms, three client bathrooms, two living rooms, a dining room, a kitchen, and an attached three car garage. LPA, accompanied by the PD, conducted a tour of the interior portions of the facility. On today's visit, there are five clients in care. LPA observed clients participating in group therapy in the dining room. LPA inspected all three client bedrooms and observed them to be free of any hazards. LPA observed client bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed client beds to have clean linens and blankets. LPA observed additional linens to be stored in a closet by the entryway of the facility. LPA inspected the three client bathrooms and observed them to be free of hazards. Faucets and toilets were operational. Hot water temperature measured between 140.7 and 143.7 degrees Fahrenheit. The PD informed LPA that the facility has their food catered by a chef. However, LPA observed the facility has a two day perishable and a seven day nonperishable food supply on hand in the kitchen. LPA observed kitchen appliances to be clean and operational. LPA observed the four burner gas stove lights unassisted. The facility does not have any kitchen knives are sharps on the premises. CONTINUED ON 809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

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: SOCAL EMPOWERED LLC	FACILITY NUMBER: 306006036
	VISIT DATE: 10/28/2025

NARRATIVE

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LPA observed fire extinguishers to be mounted on the wall on the first and second floor of the facility. Fire extinguishers were observed to be charged and serviced as of June 9, 2025. LPA tested the facility's smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their most recent emergency disaster drill on October 26, 2025.

LPA observed the centrally stored medication to be kept in a locked cabinet located in the three car garage. LPA observed the facility has a First Aid Kit stored in the garage and it had all the required components. LPA observed the door leading to the attached three car garage to be kept locked and inaccessible to clients in care. LPA observed the garage to be used for storage and laundry. LPA observed chemicals and toxins stored in the garage. LPA observed the facility has a three day emergency food and water supply to be stored in the garage.

LPA, accompanied by the PD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for client use. There is a pool located in the backyard which was observed to be adequately fenced and kept locked for client safety. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation.

LPA reviewed all five client files. All the required documentation were present and current in the client files reviewed. LPA reviewed clients' medication and medication records. LPA reviewed four staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, a deficiency is cited on the attached LIC809-D. An exit interview was conducted with Program Director Susan Kue. A copy of the report and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/28/2025 12:02 PM - It Cannot Be Edited

Created By: Brandon Lopez On 10/28/2025 at 11:52 AM

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: SOCAL EMPOWERED LLC	FACILITY NUMBER: 306006036
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, 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 tested the hot water temperature in the client bathrooms which measured between 140.7 and 143.7 degrees Fahrenheit.
	POC Due Date: 11/14/2025
	Plan of Correction
1 2 3 4	The Program Director said she will adjust the hot water temperature to be within regulatory requirements. The Program Director said she will create a water temperature log to document the hot water temperature. The Program Director agreed to send LPA the water temperature log 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
NAME OF LICENSING PROGRAM MANAGER:

	Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC809 (FAS) - (06/04)

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