306006495-12-31-2025-22-AS-EBEY-DPVTBA-20251231133451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006495
Report Date: 12/31/2025
Date Signed: 12/31/2025 01:34:57 PM

Document Has Been Signed on 12/31/2025 01:34 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 SANTA TERESA, THE		FACILITY NUMBER:	306006495
ADMINISTRATOR/ DIRECTOR:	NEPOMUCENO, MARICEL		FACILITY TYPE:	740
ADDRESS:	17698 SANTA TERESA CIRCLE		TELEPHONE:	(714) 430-7672
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 3	DATE:	12/31/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Rosendo "Carla" Miranda - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:40 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 today’s date, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management visit and requesting documentation. LPA introduced self to staff, explained the reason for the visit, and was granted entry into the facility. Administrator (AD) Rosendo "Carla" Miranda arrived shortly after and assisted with requests for documentation. During the visit, LPA requested the following documentation from facility staff and Licensee via email: - Proof of rent payments for October, November, December 2025 - Payroll records for October, November, December 2025 - Grocery receipts for October, November, December 2025 - Utility bills (water, gas and electricity) for October, November, December 2025 LPA toured the facility with AD and observed no health and safety issues. Property utilities are working, including electricity, gas, and water. Perishable and non-perishable food supply was observed adequately stocked at time of visit. It was reported that staff were not paid in a timely manner and received no response to requests for pay. Interviews were conducted and LPA received a telephone call and statement from Licensee during today’s visit. Five out of five staff and Licensee confirmed staff were not paid on time. All stated paychecks were scheduled to be paid on the 22nd day of the month and staff did not receive payment on that date. One staff stated all facility staff were paid late and received half of their pay on 12/30/25. A record review revealed four out of four staff did not receive a paycheck on 12/22/25. Two staff were paid late and two other staff had not received a paycheck by 12/31/25. Based on the observations, interviews, and records reviewed during the present visit, one Type B deficiency is being cited and CIVIL PENALTY ASSESSED. An exit interview was conducted and a copy of this report, LIC809-D, LIC421, and appeal rights were provided to a facility representative.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

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 12/31/2025 01:34 PM - It Cannot Be Edited

Created By: Eboni Bentley On 12/31/2025 at 11:29 AM

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 SANTA TERESA, THE	FACILITY NUMBER: 306006495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/07/2026 Section Cited CCR 87213	1 2 3 4 5 6 7	87213 The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee states they will pay staff in a timely manner and ensure checks are paid in full. They will send a Statement of Understanding of the CCR 87213 and state they understand, read, and provide a signature and send proof via email to eboni.bentley@dss.ca.gov by 1/7/2026.
	8 9 10 11 12 13 14	Based on observations, interviews, and record review, the paychecks due to staff were paid late and some not issued at all as today's visit. This poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2025

LIC809 (FAS) - (06/04)

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