306006360-8-12-2026-22-AS-JALE-DWVV3Y-20260812160530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006360
Report Date: 08/12/2026
Date Signed: 08/12/2026 04:05:40 PM

Document Has Been Signed on 08/12/2026 04:05 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:	WATERMARK LAGUNA NIGUEL		FACILITY NUMBER:	306006360
ADMINISTRATOR/ DIRECTOR:	JOHNNY ORTIZ		FACILITY TYPE:	740
ADDRESS:	27762 FORBES ROAD		TELEPHONE:	(949) 899-8175
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 135		CENSUS: 68	DATE:	08/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Johnny Ortiz		TIME VISIT/ INSPECTION COMPLETED:	04:15 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	Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Executive Director Johnny Ortiz and explained the reason for the visit. The Executive Director's Administrator's Certificate expires on March 15, 2028. Facility is licensed for 55 ambulatory and 68 non-ambulatory (Total capacity 135) of which 12 may be bedridden (1st floor only) and a hospice waiver for 25. Facility is one building with 3 floors and underground parking. There is a central for courtyard with a fence in the middle, one side if for memory care, one side is for assisted living, with shaded seating areas for residents to sit outside. LPA and the staff toured the facility. Memory care is located on the first floor. Assisted living is located on the second and third floors. LPA observed the See Something Say Something poster (PUB 475) posted in the main entry way of the facility. LPA toured the memory care unit. LPA observed all resident rooms had the required furnishings and bed linens. LPA tested the delayed egress exits in memory care. All the delayed egress exits in memory care are operational. Each floor has it's own medication office. LPA observed that each medication office on each floor is kept locked and medications are stored in a medication cart in the locked office. LPA inspected each first aid kit and all 3 had the required items. LPA inspected 8 resident rooms, 3 on the third floor, 3 on the second floor and 2 on the first floor. LPA observed the 8 resident rooms had the required furnishings and bed linens. Hot water measured 110.6 to 113.0 degrees Fahrenheit in the resident rooms. Each room has it's own smoke detector. All smoke detectors in the rooms inspected tested operational. The dining room and kitchen are on the second floor. LPA observed a fitness area on the second floor. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency supply of food and water stored in a storage room across from the kitchen.

Sheila Santos
Joseph Alejandre
	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

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: WATERMARK LAGUNA NIGUEL	FACILITY NUMBER: 306006360
	VISIT DATE: 08/12/2026

NARRATIVE

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The refrigerator and freezer temperatures are tracked using a temperature log. LPA observed the refrigerator temperature was 38.0 degrees Fahrenheit and the freezer was - 2.0 degrees Fahrenheit. LPA observed the fire extinguishers throughout the facility are fully charged. The facility has four stairways. Each stairway has an emergency evacuation chair. The carbon monoxide detector in the kitchen is operational. The last emergency drill was conducted on July 21, 2026. LPA observed each floor has an activity area with a TV, books, games and an area to sit. LPA toured the central outdoor courtyard. There is one courtyard area for memory care with shaded seating to sit outside. No bodies of water observed. The outdoor courtyard for assisted living has a fountain. There is shaded seating to sit outside. No obstacles or hazards observed in either courtyard.

LPA reviewed 4 staff (caregivers) files. 2 of the 4 staff members had a valid CPR/First-Aid card. All 4 staff members had 20 hours of training but no documented training for, 4 hours of training specific to postural supports, restricted health conditions and hospice care. All staff members encountered and the staff members whose files were reviewed are background cleared and associated to the facility. LPA reviewed 7 resident files and medications. No discrepancies observed.

Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR). An exit interview was conducted and a copy of the report provided along with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2026 04:05 PM - It Cannot Be Edited

Created By: Joseph Alejandre On 08/12/2026 at 03:55 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: WATERMARK LAGUNA NIGUEL	FACILITY NUMBER: 306006360
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review the licensee did not comply with the section cited above in 4 out of 4 staff members whose training files were reviewed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2026
	Plan of Correction
1 2 3 4	Administrator agrees to train care all staff on, four hours of which shall be specific to postural supports, restricted health conditions, and hospice care. Administrator to submit proof of correction to LPA by POC due 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:

	Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC809 (FAS) - (06/04)

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