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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006238
Report Date: 10/18/2023
Date Signed: 10/18/2023 09:46:07 AM


Document Has Been Signed on 10/18/2023 09:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAMINO HILLS CARE HOME 1FACILITY NUMBER:
306006238
ADMINISTRATOR:ANG, MERCEDITAFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(949) 369-8390
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
10/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maricris LafigueraTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Maricris Lafiguera, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 09/01/2022. This is a change of ownership with persons in care. This is the second pre-licensing inspection. Please see LIC809 dated 06/20/2023.

During the initial inspection, the LPA and AP observed the following: the fire clearance granted on 01/17/2023 allowed for 2 Non-Ambulatory, 2 Ambulatory, and 2 Bedridden residents. However, all residents residing at the facility were Non-Ambulatory. AP stated they would obtain a new fire clearance to resolve the issue.

Since the initial pre-licensing inspection, AP obtained a new fire clearance from Orange County Fire Authority dated 09/12/2023 which allows for 6 Bedridden residents. During today’s inspection, LPA toured the facility with AP and confirmed the facility is following the new fire clearance. The issue noted during the initial pre-licensing inspection has been addressed.

AP has requested a hospice waiver for 3 and LPA confirmed there are 3 residents currently on hospice at the facility. AP stated they would like to increase the hospice waiver either before or after licensure. LPA advised AP to follow the current hospice waiver until a new one is approved. AP stated they understood and agreed.

LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. Component III was waived during the initial pre-licensing inspection. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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