306006150-7-17-2025-22-AS-JALE-DJNRGZ-20250717130134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006150
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:01:49 PM

Document Has Been Signed on 07/17/2025 01:01 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:	CALIFORNIA CARE MENTAL HEALTH		FACILITY NUMBER:	306006150
ADMINISTRATOR/ DIRECTOR:	BOUQUET, JASON		FACILITY TYPE:	772
ADDRESS:	25542 DANA MESA DR		TELEPHONE:	(949) 291-3333
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 6		CENSUS: 3	DATE:	07/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:25 AM
MET WITH:	Hayley Montes		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Lead staff member Hayley Montes and explained the reason for the visit. Facility has 3 bedrooms, 2 bathrooms, living room, kitchen, staff office, and an attached two car garage. In the backyard there is a one room building that is a therapy room, this building was part of the fire clearance report and is approved for use as a therapy room. Facility is licensed as a Transitional Social Rehabilitation Facility for 6 ambulatory clients. LPA and staff toured the facility. LPA observed a seating area in the living room with a large screen TV. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry of the facility. LPA observed the facility license, facility certification certificate from the Department of Health Care Services posted next to the front entrance along with personal rights of residents/clients. The fire extinguishers in the kitchen and hallway are fully charged. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply in the kitchen. LPA observed the medications and knives are kept locked in the staff office. Cleaning supplies are kept locked in the hall closet. LPA observed that the 3 client bedrooms had the required furnishings and bed linens. LPA observed both bathrooms are clean and operational. Hot water measured 120.0 degrees Fahrenheit in both bathrooms. LPA observed clean linens and towels stored in the hall closet. No obstacles or hazards observed inside of the facility. The garage has a portable air conditioner and is used as an exercise room. Staff reported that clients are not allowed in the garage without a staff member. The fire extinguisher in the garage is fully charged. LPA observed a 3 day supply of emergency food and water in the garage. LPA toured the backyard. No bodies of water observed. There is a covered patio with shaded seating in the backyard. LPA observed the therapy room in the backyard. The therapy room is kept locked and it is only used with a client and a therapist.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

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: CALIFORNIA CARE MENTAL HEALTH	FACILITY NUMBER: 306006150
	VISIT DATE: 07/17/2025

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LPA observed the therapy room has a couch, desk and a chair. No obstacles or hazards observed in the therapy room. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed 3 client files and medications. No discrepancies observed. LPA reviewed 3 staff files. No discrepancies observed. All 3 staff had the required training including first aid training. All 3 staff are background cleared and associated to the facility. LPA inspected the first aid kit. The first aid kit had all the required elements. The last emergency drill was conducted on July 1, 2025. No deficiencies are being cited as a result of this visit. 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: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC809 (FAS) - (06/04)

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