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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006565
Report Date: 09/01/2026
Date Signed: 09/01/2026 12:56:11 PM

Document Has Been Signed on 09/01/2026 12:56 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:
09/01/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Caregiver Valeria Palomera OchoaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On September 1, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Health Checks. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee (LI) Allen Medina was notified of the visit but was unable to assist with today's inspection.

On today's visit, there were two residents in care and there was one care giving staff present. LPA, accompanied by the 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. Hot water temperature measured between 105.6 and 105.9 degrees Fahrenheit.

LPA inspected the facility's kitchen area and observed it to be clean. LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed the facility has a three day emergency food and water supply stored in the pantry. LPA, accompanied by the staff, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be free of any hazards or obstructions. No health or safety concerns were observed during the visit. LPA observed all of the facilities utilities to be operational during the visit. LPA additionally conducted interviews with the two residents and one staff of the facility during the visit. LPA also conducted an interview with the landlord of the property, Witness #1 (W1), during the visit. W1 advised LPA that the facility still has not paid the last three months rent and still owe approximately $22,500.00. CONTINUED ON LIC809-C
Sheila Santos
Brandon Lopez
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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: HILLS OF SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565
VISIT DATE: 09/01/2026
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W1 also provided LPA a copy of the unlawful detainer that was filed against the Licensee on July 27, 2026, as a result of their missed rent payments. According to California Code of Regulation Section 87211(d)(2), it states: "(d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events, or knowledge thereof: (2) An unlawful detainer action is initiated against the licensee. However, Community Care Licensing was not informed by the Licensee regarding the unlawful detainer. LPA also conducted an interview with the Responsibly Party for Resident #1 (R1), Witness #2 (W2). W2 advised LPA that they were not aware of the unlawful detainer and confirmed that the Licensee of the facility did not inform them of it. W2 also advised LPA that they were unaware of the proceedings initiated against the Licensee by Community Care Licensing. W2 stated that the Licensee of the facility did not provide them with a written notice of the commencing of the proceedings. Additionally, during the visit, LPA observed that the facility did not have a copy of the notice regarding their legal proceedings, despite them being previously advised to post it.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D pages. The Licensee will be issued a civil penalty in the amount of $250.00 for a repeat violation. The Licensee was previously issued a citation under California Code of Regulation, Title 22, Section 87213, on August 12, 2026. The Licensee will be issued a second civil penalty in the amount of $250.00 for a repeat violation. The Licensee was previously issued a citation under Health and Safety Code 1569.38(b)(1) on July 7, 2026. The Licensee will be issued a third civil penalty in the amount of $250.00 for a repeat violation. The Licensee was previously issued a citation under Health and Safety Code 1569.38(e) on August 12, 2026. LPA called Licensee Allen Medina via telephone to conduct an exit interview, however, Licensee Allen Medina did not answer. A copy of the report was provided at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/01/2026 12:56 PM - It Cannot Be Edited


Created By: Brandon Lopez On 09/01/2026 at 12:31 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: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87213

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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...
This requirement was not evidenced by:
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The Licensee will provide LPA a written financial plan on how they will address the facility's outstanding rent balance and the unlawful detainer. The Licensee will 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 have an unlawful detainer filed against them. This poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
09/02/2026
Section Cited
HSC1569.38(b)(1)

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§1569.38 Posting of licensing reports; disclosure to new residents: (b) A licensed... facility.. shall provide written notice to a resident, the resident’s responsible party .. within 10 days.. (1) The department commences proceedings to..revoke the license of the facility..
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The Licensee will provide the written notices to the two residents, and their responsible parties, of the facility regarding the proceedings. The Licensee will provide LPA proof of the written notice via email or fax by POC due date. LPA to follow up with residents and their responsible parties.
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This requirement is not evidenced by: Based on interviews conducted, the Licensee did not ensure that residents and their responsibly parties were notified of proceedings to revoke the facility's license within 10 days. 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: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/01/2026 12:56 PM - It Cannot Be Edited


Created By: Brandon Lopez On 09/01/2026 at 12:36 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: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2026
Section Cited
CCR
87211(d)(2)

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87211 Reporting Requirements: (d) The licensee shall notify the Department,.., all residents,..., their representatives, in writing within two business days of any of the following specified events, or knowledge thereof: (2) An unlawful detainer action is initiated against the licensee.
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The Licensee will provide a written notice to Community Care Licensing, the residents, and their representatives regarding the unlawful detainer. The Licensee will provide proof of the written notices being sent to LPA via email or fax by POC due date.
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This requirement is not evidenced by: Based on records & interviews, the Licensee did not notify the Department, residents, or their representatives regarding the unlawful detainer filed against them. This poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
09/02/2026
Section Cited
HSC1569.38(e)

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§1569.38 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..
This requirement is not evidenced by:
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The Licensee will print and post a copy of the notice of the proceeding in the facility. The Licensee will 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: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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