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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006502
Report Date: 05/09/2025
Date Signed: 05/09/2025 12:53:03 PM

Document Has Been Signed on 05/09/2025 12:53 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:CALLE DEL CID GUEST HOMEFACILITY NUMBER:
306006502
ADMINISTRATOR/
DIRECTOR:		CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:27281 CALLE DEL CIDTELEPHONE:
(949) 573-6489
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
05/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:15 AM
MET WITH:Akichelle Regala- Caregiver
Buenaventura Certeza- Caregiver
Dionisio Tagle- Caregiver		TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Buenaventura Certeza and explained the reason for the visit. Administrator (Admin) Priscilla Celis was unable to come to the facility and authorized staff on duty to sign the report. Admin Celis holds a valid certificate expiring on July 5, 2025.

The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory. A waiver was granted to provide hospice services to six residents at one time. During today's visit, there are five residents under hospice care and three caregivers on duty.

LPA toured the physical plant with Caregiver Akiechelle Regala. Facility was clean and operational with the exception of the refrigerator and freezer which required a deep cleaning as food debris and stains were observed. LPA observed five resident bedrooms and three resident bathrooms. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 119.4, 113.7, and 114.9 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient emergency food and water in the garage and kitchen pantry. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was mounted and serviced on April 11, 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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 05/09/2025 12:53 PM - It Cannot Be Edited


Created By: Jessica Cho On 05/09/2025 at 12:18 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: CALLE DEL CID GUEST HOME
FACILITY NUMBER: 306006502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 in two out of three resident's medications reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Adminstrator stated that proof of staff-inservice medication training and Acknowledgement of Understanding for the said deficiency will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


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: CALLE DEL CID GUEST HOME
FACILITY NUMBER: 306006502
VISIT DATE: 05/09/2025
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Emergency evacuation drills are conducted quarterly. Last drill was conducted on February 26, 2025. The facility land line number, (949) 215-1591, was tested and remains available. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the entry way in the correct size.

LPA conducted a review of all residents and two staff files. Interviews were conducted with residents and staff. Medications were audited, and discrepancies were observed.

The following items were addressed with the Admin by telephone at 11:47am: to deep clean refrigerator and freezer, to assemble emergency supplies in one central location, to complete the Medication Administration Record (MARs) at the time medications are administered, to maintain an accurate and up to date list of medications on the MAR, and to ensure as needed (PRN) medications are not transferred into a different container in advance.

Based on the observations made during today's visit, a deficiency is being cited and Advisory Notes (LIC9102s) are also being issued.

An exit interview was conducted with Caregivers Akiechelle Regala, Buenaventura Certeza, and Dionisio Tagle, and a copy of this report including the LIC809C, LIC809D, LIC9102s, LIC811, and the appeal rights were provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
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