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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006492
Report Date: 07/17/2025
Date Signed: 07/17/2025 02:34:29 PM

Document Has Been Signed on 07/17/2025 02:34 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, THEFACILITY NUMBER:
306006492
ADMINISTRATOR/
DIRECTOR:		CUYSON, ELEAZARFACILITY TYPE:
740
ADDRESS:27041 MALLORCA LANETELEPHONE:
(714) 430-7672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Eleazar Cuyson was notified via telephone and arrived later to assist with the visit.

There are currently six residents in care, three of which are receiving hospice care at this time. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a two-story house with an attached garage, with two private bedrooms, two shared bedrooms. There are are one shared and one en-suite bathrooms on the premises. The upstairs portion of the house is strictly for staff use and verified not to house any residents during the visit.

Bedrooms appear clean and sanitary. Two resident receiving hospice care are observed to have a bed equipped with full-length bed rails. Hospice plans of care reviewed. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 126.2F and 132.2F at two separate faucets used for personal grooming. Type A deficiency cited and civil penalty assessed for repeat violation..

LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secure.

The fire extinguishers present are charged with up-to-date maintenance tag. Carbon monoxide and smoke detectors were found to be present and operational. CONTINUED ON FORM LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
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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Document Has Been Signed on 07/17/2025 02:34 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 07/17/2025 at 01:47 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: HILLS OF MALLORCA, THE
FACILITY NUMBER: 306006492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the two bathrooms faucets used for personal grooming were measured to be delivering water at 126F and 132F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will adjust the water heater temperature to ensure delivery of hot water below 120F. Proof of adjustement to be provided to LPA before the plan of completion due date. Penalty assessed for repeat violation.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, the licensee did not comply with the section cited above as two residents were found to be assessed to be bedridden per their most recent physicial report while the facility's fire clearance does not include bedridden residents at the time of the visit. This poses an immediate health, safety or personal rights risk to persons in care. Immediate civil penalty assessed.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee to submit statement of acknowledgement of the applicable requirement before submitting an updated LIC200 form to the Department in order to schedule a new visit from the fire marshall.
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:
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


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: 07/17/2025
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CONTINUED FROM LIC809
The garage is secured and used for the storage of supplies and food as well as the laundry area. Emergency food and water supplies verified to be present. All utilities (gas, water, electricity, internet and cable) are verified to be operational during the visit. Fresh groceries are also present.

LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. There are no bodies of water on the premises. Egress alarms are in use on exit doors, however facility does not utilize locked perimeters or delayed egress.

LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all six residents with no discrepancies observed. Two residents are found to have been assessed as bedridden per their latest physician reports, however the current fire clearance does not include a provision for bedridden residents. Type A deficiency cited and immediate civil penalty assessed due to the failure to meet the requirements of the fire clearance.

LPA reviewed staff records for three staff members present during the visit. CPR training, initial and annual training reviewed for 2024 and 2025. Disaster drills are conducted and documented. Staff members are verified to be background cleared and associated to the licensed location.

Based on the observations conducted during the present visit, two type A deficiencies are being cited per Title 22 of the California Code of Regulations. A civil penalty for repeat violation along with an immediate civil penalty were assessed during the visit. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
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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