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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006674
Report Date: 04/14/2026
Date Signed: 04/14/2026 05:00:59 PM

Document Has Been Signed on 04/14/2026 05:00 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:PACIFIC BAY SENIOR LIVINGFACILITY NUMBER:
306006674
ADMINISTRATOR/
DIRECTOR:		LEE, YOUNGFACILITY TYPE:
740
ADDRESS:8562 ORINDA CIRCLETELEPHONE:
(310) 308-5102
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
04/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:24 PM
MET WITH:GisTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by staff after explaining the purpose of the visit. LPA was assisted by caregiver Edison Canlas and later assisted by caregiver Giselle Enebrad who later arrived. LPA observed the administrator certificate was current with an expiration date of June 18 ,2027. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a one-story home with five resident bedrooms, three bathrooms, living room, kitchen, dining room and an attached garage.

During the inspection, LPA and caregiver conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

LPA observed residents watching television in their respective bedrooms. LPA observed four residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the entryway. LPA observed that all resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway storage closet. LPA observed bathrooms were clean and equipped with grab bars, toilet paper, paper towels, and non-skid floor mats. Bathrooms were observed to be free of debris and mildew. Faucets and toilets were operational. Water temperature tested between 103.3 and 114.6 degrees Fahrenheit. LPA observed all windows were appropriately screened. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use.

Continued LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2026
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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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: PACIFIC BAY SENIOR LIVING
FACILITY NUMBER: 306006674
VISIT DATE: 04/14/2026
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LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Gas stove, microwave, washer, dryer and dishwasher were inspected and observed to be operable. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a purchase date of March 15, 2026 and located by the dinning table and the living room. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents under the kitchen sink and in the garage. Medication cabinet was observed to be locked and centrally stored in a hallway closet. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on January 10, 2026 and is conducted every 3 months.

LPA began review of the records. LPA reviewed four resident records. All the required documentation were present and current in the resident files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate.



Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, LIC 9102 and the Legionnaire’s Disease fact sheet was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC809 (FAS) - (06/04)
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