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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006503
Report Date: 07/01/2024
Date Signed: 07/01/2024 11:24:30 AM


Document Has Been Signed on 07/01/2024 11:24 AM - 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:HORIZON SENIOR LIVING, LLCFACILITY NUMBER:
306006503
ADMINISTRATOR:ARONNE, CELFAFACILITY TYPE:
740
ADDRESS:25351 DIANA CIRCLETELEPHONE:
(949) 500-3760
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Celfa Aronne, Prospective licenseeTIME COMPLETED:
11:45 AM
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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 Celfa Aronne, administrator.

An initial application for a license to operate as a Residential Care Facility for the Elderly was received by the Department on February 5, 2024 for a capacity of six non-ambulatory clients. This is a change of ownership with four residents already in care.

LPA accompanied by administrator toured the physical plant. The facility is a one-level home with a frontyard, backyard and attached garage. There are four individual bedrooms and one shared bedroom. 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. There are two bathrooms on the premises, one of which is mostly designated for use by the residents. Water temperature was measured to be within acceptable range. Common living spaces are present and a device connected to the internet is present for the use of the clients in care. Facility is clean, sanitary and free of odors in all areas inspected. Required posted documents are observed to be present, with the exception of the facility's theft and loss policy. Policy will be posted shortly and documentation provided to LPA.

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 cupboard. The garage is also used for additional storage of food along with emergency and back-up supplies. Staff and client records were reviewed and confirmed to include all necessary components.
CONTINUED ON FORM LIC809-D
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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: HORIZON SENIOR LIVING, LLC
FACILITY NUMBER: 306006503
VISIT DATE: 07/01/2024
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CONTINUED FROM FORM LIC809
Three out of four residents currently admitted are receiving hospice care. Prospective licensee is instructed to request an updated hospice waiver prior to receiving the license, for a capacity of three or more residents. Materials submitted to include a request letter addressed to the Orange County Regional Manager, current plan of care materials for all three residents in addition to any other supporting material

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. Two fire extinguishers present on the premises are observed to have maintenance tags indicating they were last verified to be operational in November 2022. Consultation is provided to the licensee regarding the need for annual maintenance of fire extinguishers. The fire extinguishers will be verified by a third-party and proof of maintenance will be submitted to LPA shortly. First aid kit verified to be complete.

LPA and licensee toured the outside of the facility and observed it to be free of obstructions. Multiple shaded areas are present in the back of the house and are 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. 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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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