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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006565
Report Date: 08/12/2026
Date Signed: 08/12/2026 03:24:42 PM

Document Has Been Signed on 08/12/2026 03:24 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 SIERRA MAJORCA, THEFACILITY NUMBER:
306006565
ADMINISTRATOR/
DIRECTOR:		LADIA, BHONALYNFACILITY TYPE:
740
ADDRESS:19105 SIERRA MAJORCATELEPHONE:
(949) 316-4654
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 6CENSUS: 2DATE:
08/12/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Licensee Maricel Nepomuceno via telephoneTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On August 12, 2026, at 12 PM, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Licensee (LI) Maricel Nepomuceno was notified via telephone but was unable to assist with the inspection.

On today's visit, the facility has a census of three residents, however, there were only two resident physically present during the visit. LPA also observed two care giving staff present. LPA, accompanied by a caregiver staff, conducted a tour of the physical plant. LPA inspected the five resident bedrooms and observed them to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed the lights in each of the resident's bedroom to be operational. LPA inspected the three shared resident bathrooms located in the facility and observed bathrooms to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. LPA attempted to test the hot water temperature and observed that the facility did not have any water. Per the facility staff present, the water was shut off upon LPA's arrival to the facility at approximately 12 PM.

LPA inspected the kitchen area and observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed the remaining utilities, such as the electricity, gas, and internet, to be operational during the visit. LPA conducted a tour of the exterior portions of the facility and observed it to be free of any hazards.
CONTINUED ON LIC809-C
Sheila Santos
Brandon Lopez
DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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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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 SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565
VISIT DATE: 08/12/2026
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 LPA additionally conducted interviews with two staff and the residents present during the visit. LPA then made telephone calls to Licensees Allen Medina and Maricel Nepomuceno to make them aware of the water being shut off at the facility. Licensee Maricel Nepomuceno confirmed that the water had been shut off due to the facility having an outstanding balance in their water bill. LPA requested and reviewed the facility's water bill for July 2026, and observed that the facility had an overdue balance in the amount of $1,337.33. The Licensees were able to restore the facility water at approximately 3 PM, meaning the facility did not have water for approximately two hours.

During the visit, LPA also made a telephone call to the landlord of the property, Witness #1 (W1). W1 said that the facility has not paid their monthly rent for the last three months. W1 said that the facility currently owes approximately $22,500.00 in past due rent. W1 said that they are also pursuing an eviction as a result of unpaid rent. On May 8, 2026, the Department notified the Licensees that they have began proceedings to revoke the license of the facility. Per Health and Safety Code Section 1569.38(e): "(e) Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include where the mail boxes are located, where the facility license is posted, or any other easily accessible location in the facility. The posting shall include all of the following information:" On today's visit, over ninety days after the Licensees were notified of the proceedings, LPA observed that the facility did not have a copy of the notice posted in the facility.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. A civil penalty will also be assessed in the amount of $250.00 for a repeat violation. The Licensees were previously issued a citation under California Code of Regulation, Title 22, Section 87213, on March 26, 2026. An exit interview was conducted with Licensee Maricel Nepomuceno via telephone. A copy of the report and appeal rights were provided to the facility at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/12/2026 03:24 PM - It Cannot Be Edited


Created By: Brandon Lopez On 08/12/2026 at 02:07 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 SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2026
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement was not evidenced by:
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The Licensee was able to restore the facility's water after approximately two hours by paying the past due balance. POC cleared at time of visit.
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Based on observation, the Licensee did not ensure the facility had water as the facility was experiencing a water shutoff upon LPA's arrival to the facility. The facility remained without water for approximately two hours. This poses and immediate health, safety, and personal rights risk to persons in care.
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Type A
08/13/2026
Section Cited
CCR87213

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87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency...
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The Licensee stated that they will provide LPA a written financial plan on how they will address the facility's outstanding rent balance and ensure utilities are operational. The Licensee agreed to provide LPA the written plan via email or fax by POC date.
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Based on observations & records reviewed, the Licensee does not have a sufficient financial plan as the facility has an overdue balance of $22,500 in past due rent and of $1,337.33 in their water bill. This poses an immediate health, safety, and personal rights risk to persons in care.
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2026 03:24 PM - It Cannot Be Edited


Created By: Brandon Lopez On 08/12/2026 at 02:12 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 SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2026
Section Cited
HSC
1569.38(e)

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ยง1569.38 Posting of licensing reports; disclosure to new residents: (e) Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice.. in the facility..
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The Licensee stated that they will print and post a copy of the notice of the proceeding in the facility. The Licensee agreed to provide LPA proof of posting of the notice via email or fax by POC due date. LPA will also conduct a follow up visit to confirm the notice has been posted.
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Based on observation, the Licensee did not ensure that a notice regarding the proceedings from Community Care Licensing was posted at the facility during today's visit. This poses an immediate health and safety risk to persons in care.
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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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2026


LIC809 (FAS) - (06/04)
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