306006700-7-7-2026-22-AS-RMRT-DVS2A7-20260707171304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006700
Report Date: 07/07/2026
Date Signed: 07/07/2026 05:13:26 PM

Document Has Been Signed on 07/07/2026 05:13 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:	SIERRA VISTA SENIOR LIVING II		FACILITY NUMBER:	306006700
ADMINISTRATOR/ DIRECTOR:	ARIAS, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	2533 E LIZBETH AVE		TELEPHONE:	(949) 537-1310
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY: 6		CENSUS: 4	DATE:	07/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Alexander Arias, Administrator (AD)		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert and Regional Manager (RM) Monica Tran made an unannounced visit to conduct an Annual Required Evaluation. LPA and RM were greeted and granted entry by Staff #1 (S1) at 1:15pm. LPA and RM met with Administrator (AD) Alexander Arias and explained the purpose of the visit. The facility is a single-story, five bedroom, two bathroom residential home with an approved fire clearance of six non-ambulatory and an approved hospice waiver for six. Currently there are five residents in care with one resident receiving hospice services. During the visit LPA spoke with Administrator (AD) Arias regarding licensing fees due on July 24, 2026. AD spoke with the office and obtained the information to avoid late payment. LPA and RM toured the facility and inspected the smoke and carbon monoxide detectors. Smoke and carbon monoxide detectors were operational. The fire extinguisher was charged and inspected in January 2026. The facility's last fire drill was on June 1, 2026. LPA and RM tested the hot water temperature in two of two bathrooms. The hot water temperature ranged from 123.2 to 125.0 degrees Fahrenheit. A deficiency will be cited. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. All appliances were operational and emergency supplies were observed in the garage. RM observed medication storage and reviewed the centrally stored medications. A deficiency will be given regarding medication documentation and over-the-counter medications for one of five residents. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

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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Document Has Been Signed on 07/07/2026 05:13 PM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 07/07/2026 at 04:33 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: SIERRA VISTA SENIOR LIVING II	FACILITY NUMBER: 306006700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in two of two bathrooms which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/08/2026
	Plan of Correction
1 2 3 4	AD will email/text LPA a photo of the temperature in two of two resident bathrooms by POC due date.

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and RM's observations, interviews and Medication Administration Record review, the licensee did not comply with the section cited above in one of five residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/08/2026
	Plan of Correction
1 2 3 4	AD communicated with home health nurse to discard over-the-counter medications. AD will inservice staff members on medication documentation and storage and will email LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2026 05:13 PM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 07/07/2026 at 04:33 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: SIERRA VISTA SENIOR LIVING II	FACILITY NUMBER: 306006700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87456(a)(3)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and RM file review, the licensee did not comply with the section cited above in one of five residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2026
	Plan of Correction
1 2 3 4	Administrator will obtain updated Medical Assessment by Plan of Correction date for one of five residents. AD will email LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

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: SIERRA VISTA SENIOR LIVING II	FACILITY NUMBER: 306006700
	VISIT DATE: 07/07/2026

NARRATIVE

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(Continued from LIC 809)

LPA and RM toured the exterior of the facility and observed a shaded seating area and two self-latching exit doors. There is ample room for activities and there were no hazards or obstructions in pathways. There is a camera located in the living room and it is visual only.

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. One of five residents did not have an updated Medical Assessment. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 19, 2028.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Alexander Arias, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026

LIC809 (FAS) - (06/04)

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