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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006949
Report Date: 06/05/2026
Date Signed: 06/05/2026 09:31:16 AM

Document Has Been Signed on 06/05/2026 09:31 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:EVERCARE MANORFACILITY NUMBER:
306006949
ADMINISTRATOR/
DIRECTOR:		CELIS, PRISCILLAFACILITY TYPE:
740
ADDRESS:24621 DARDANIA AVETELEPHONE:
(949) 573-6489
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 0DATE:
06/05/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Priscilla Celis- Applicant/Administrator
Liza Rebecca- Administrator		TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived announced for the purpose of conducting a Pre-Licensing visit using the Care Inspection Tool. LPA conducted the visit with Applicant Priscilla Celis and Administrator Liza Rebecca. An initial application to operate a Residential Care Facility for the Elderly (RCFE), age range 60 and over, for (6) non-ambulatory, of which (1) may be bedridden was received by the Department on March 23, 2026. All bedrooms are approved for non-ambulatory or bedridden, where only (1) bedridden resident can be served at one time with a waiver granted for care for (6).

LPA toured the interior and exterior portion of the facility and observed the following accompanied by the Applicant Priscilla Celis and Administrator Liza Rebecca.

Structure:


The facility is a single story property in a residential neighborhood. The facility is comprised of four (4) private resident bedrooms, (1) shared resident bedroom, (1) shared staff bedroom, and (2) full resident bathrooms. There is a living room, formal dining area, office, kitchen, laundry room, an attached two car garage, and a backyard. The backyard has one exit gate on one side of the property. There is a shaded seating area. LPA did not observe any obstacles or hazards in the backyard.

Signal System:
The facility utilizes a signal system where staff is alerted from a central location located in the kitchen area via the call buttons.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2026
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: EVERCARE MANOR
FACILITY NUMBER: 306006949
VISIT DATE: 06/05/2026
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Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

Bathrooms:
Bathrooms were clean and operational. Grab bars were secure and slip resistant mats were in place.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies were observed to be fully stocked.

Appliances:
Stove burners, microwaves, washer, and dryer were inspected, new, and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site in the kitchen.

Reading Material, Games, Equipment, & Materials:
The facility maintains activities and games in the formal dining room.

Emergency Phone Numbers/Exit Plan:
Posted in the medication cabinet and available for review upon request

Postings:
The See Something, Say Something (PUB475) and the Ombudsman Posters were posted in the entry area of the facility. Also posted were the Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and Food Menu. The Admission Agreement is in the medication cabinet and will be available for review upon request.

Food Service and Menu:
Facility exceeded the seven day non-perishable and two day perishable food supply. The sample menu was available. The emergency food/water supply was also available.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
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: EVERCARE MANOR
FACILITY NUMBER: 306006949
VISIT DATE: 06/05/2026
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Smoke and Carbon Monoxide Detectors:
The dual functioning smoke/carbon monoxide detectors, (2) carbon monoxide alert systems, and auditory devices were tested and found to be operational.

Fire Extinguisher:
One fire extinguisher was mounted, fully charged, and purchased on March 28, 2026. .

Fire Clearance:
Approved on April 15, 2026 for (5) non-ambulatory residents and (1) bedridden resident.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were secured and inaccessible.

Water Temperature:
The water temperature in the resident bathrooms measured at 116.6 in the primary and 117.8 degrees Fahrenheit in the second bathroom.

Medications, First Aid Kit & Manual:
The First Aid Kit was checked and found to be in order including the First Aid Manual.


Component III:
Component III is waived due to the applicant currently operating a licensed facility and having completed the training previously.

The Pre-Licensing is now complete, and the facility is ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Applicant/Administrator Priscilla Celis and Administrator Liza Rebecca, and a copy of this report was provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026
LIC809 (FAS) - (06/04)
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