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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006641
Report Date: 02/11/2025
Date Signed: 02/11/2025 10:48:07 AM

Document Has Been Signed on 02/11/2025 10:48 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:QUALITY SENIOR LIVING AT MORENAFACILITY NUMBER:
306006641
ADMINISTRATOR/
DIRECTOR:		TENTE, MARIAFACILITY TYPE:
740
ADDRESS:26791 MORENA DRIVETELEPHONE:
(657) 223-9264
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
02/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nickolas LacsonTIME VISIT/
INSPECTION COMPLETED:
10:03 AM
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Licensing Program Analyst (LPA) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Licensee (LE) Nickolas Lacson and Administrator (AD) Maria Tente.

An application to operate a Residential Care Facility for Elderly (RCFE) was received by our agency on October 9, 2024 for a total capacity of six; six non ambulatory and one maybe bedridden with a hospice waiver for two. There are currently four residents residing in the facility, Quality Senior Living Home #2 RCFE #306004700, that is to be transferred to PHV 3 RCFE LLC., doing business as Quality Senior Living at Morena. Fire clearance was approved by a fire inspector from the Orange County Fire Authority on December 4, 2024.

The facility is a one-story home with five resident bedrooms, a caregiver room, four bathrooms, a living room, a family room, a kitchen, a dining area, and an attached car garage. All exiting doors had alarm notifications. There are two backyard exit gates on each side of the house that is self-latching and unlocked. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

LPA observed Administrator certificate, See Something, Say Something poster (PUB 475), Personal Rights, Ombudsman poster, Facility sketch and Emergency Disaster Plan in the facility mounted on the wall by the front entryway and the office area in the family room. Fire extinguisher is in the kitchen fully charged.

Resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents is stored and locked in the garage. Medications were stored in a locked filing cabinet in the staff office area. The first aid kit is also stored in the locked medication filing cabinet. Staff and resident records are stored in the staff office area in the family room.

Pre-Licensing continuation on LIC809-C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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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: QUALITY SENIOR LIVING AT MORENA
FACILITY NUMBER: 306006641
VISIT DATE: 02/11/2025
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Games and puzzles were observed in the front entry way and living room. The phone is in the staff office area in the family room for residents to use, as well as a computer.

A supply of perishable and non-perishable food was observed. Smoke detectors and carbon monoxide detectors tested operational. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. There are cameras placed in the common areas of the facility without audio for the safety of residents in care. Hot water temperatures in the bathrooms measured between 118.5 and 120.5 F degrees. Emergency food and water and additional supplies were observed to be well stocked in the kitchen pantry.



The facility is ready to be licensed. LPA conducted the Component Three Orientation with LE and AD. Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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