306006492-7-19-2024-22-AS-KSGH-D7BUU9-20240719155309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006492
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:53:57 PM

Document Has Been Signed on 07/19/2024 03:53 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:	HILLS OF MALLORCA, THE		FACILITY NUMBER:	306006492
ADMINISTRATOR:	CUYSON, ELEAZAR		FACILITY TYPE:	740
ADDRESS:	27041 MALLORCA LANE		TELEPHONE:	(714) 430-7672
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	07/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eleazar Cuyson, Administrator Maricel Nepomuceno, licensee		TIME COMPLETED:	04:10 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting a pre-licensing inspection. LPA was greeted and granted entry by Maricel Nepomuceno, licensee. An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on January 16, 2023 for a capacity of six non-ambulatory residents. This is a change of ownership with five residents already in care. All five of the currently admitted individuals are receiving hospice care. The applicant has requested a hospice waiver for six residents. LPA accompanied by administrator toured the physical plant. The facility is a two-level home with a frontyard, backyard and attached garage, with the entire second floor dedicated to staff dwellings and administrative offices. There are two shared bedrooms and two private bedrooms with one shared bathroom. Each of the bedrooms include all necessary components of furnishing including a light, chair, storage space for personal items and a full-size bed as well as a supply of linen and bedsheets. Water temperature was measured at 122F, which is higher than the maximum required of 120F. Common living spaces are present and a device connected to the internet is present for the use of the residents in care. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present. Kitchen equipment is present and operating as required. Sharp items and cleaning supplies are confirmed to be secured. A sufficient supply of perishable and non-perishable food is present as required by Title 22 Regulations. The centrally stored medication storage is located in a secure cabinet with a digital combination lock. The garage is used for additional storage of food along with emergency and back-up supplies along with a laundry area. The entrance to the garage is also secured with a digital lock. Sound alarms are present on the other ways of egress. CONTINUED ON FORM LIC809-D

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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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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: HILLS OF MALLORCA, THE	FACILITY NUMBER: 306006492
	VISIT DATE: 07/19/2024

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CONTINUED FROM FORM LIC809

Staff and five client records were reviewed and confirmed to include all necessary components, with the exception of one outdated medical assessment for one of the residents with a dementia diagnosis. The resident in question has been assessed by the hospice physician upon admission into hospice, however the assessment form is missing a date and signature when reviewed during the visit.

The fire clearance has been obtained and provided to the Department before the pre-licensing visit. Combined smoke and carbon monoxide detectors are observed throughout the facility and confirmed to be functional. Fire extinguishers present on the premises are observed to be charged with current maintenance tags. First aid kit verified to be complete.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. One shaded area is present in the backyard and is equipped with outdoor furniture for the enjoyment of residents and visitors. The perimeter gates present on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Component III was waived as the prospective licensee has already been acting as the current facility administrator and operates other licensed locations as well. This report was reviewed with facility representative and a copy of this report was emailed to the prospective licensee before the conclusion of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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