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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006958
Report Date: 09/28/2026
Date Signed: 09/28/2026 10:36:10 AM

Document Has Been Signed on 09/28/2026 10:36 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:LOVED ONES SENIOR LIVINGFACILITY NUMBER:
306006958
ADMINISTRATOR/
DIRECTOR:		DAMIEN MARTINEZFACILITY TYPE:
740
ADDRESS:24671 ELOISA DRIVETELEPHONE:
(949) 312-7737
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
09/28/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Damien Martinez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Taylor Simerly made an announced visit to conduct a pre-licensing inspection. LPA identified them self and discussed the purpose of the visit with Damien Martinez, Administrator. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing on March 13, 2026, for a capacity of six clients, five can be non-ambulatory and one bedridden. Facility has all required postings. Administrator Damien Martinez has an administrator certificate expiring on November 25, 2027.

LPA along with Administrator toured the facility at 9:00 AM and observed the following:

Structure: Facility is a one story home with five client bedrooms, one staff room, two bathrooms, living room, dining room, kitchen and an attached garage. Living Room/ Dining Room: Adequate seating is available in the dining room and living area. Bedrooms- Clients: One bedroom is a double occupancy and the other four client rooms are private rooms. All rooms are equipped with appropriate lighting and ample storage space. Staffroom: There is one staff one according to the fire clearance off of the kitchen before the garage. Linens & Hygiene Supplies: Facility has ample bedding and towels in supply as well as hygiene supplies. Bathrooms: All client bathrooms have a working toilet/ wash basin as well as soap. Emergency Phone Numbers and Exit Plan: Posted in the entrance of the facility. Food Service: LPA observed the kitchen area. Facility has a two day perishable and seven day non perishable food supply.

CONTINUED ON LIC 9099C

Alfonso Iniguez
Taylor Simerly
DATE: 09/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2026
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: LOVED ONES SENIOR LIVING
FACILITY NUMBER: 306006958
VISIT DATE: 09/28/2026
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Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Appliances: Kitchen and laundry appliances are clean and operational. Cook top burners are operational. Toxins/ Sharps: Facility has a secured area for toxins and sharps in the kitchen. Water Temperature: Tested and recorded between 115.6 to 117 degrees F. in facility restrooms. Emergency Supplies: LPA observed ample emergency food and water as well as emergency supplies in the garage. Medications, First-Aid Kit & Book: First aid kit observed contained all required items including tweezers, scissors and thermometer. Medications are stored in a locked closet in the hallway. Facility utilizes medication administration record. Resident & Staff File: Records are stored in the locked hallway closet. Reading Material, Games, and Equipment: LPA observed a sample activity schedule with activities such as outings in the community and exercise. Outside areas: LPA observed an outside area with ample shaded seating. LPA observed one exit gate in the backyard. Fire Clearance: Approved for six clients, five of which can be non-ambulatory and one bedridden on May 18, 2026.

Component III conducted during the visit.



The facility is ready to be licensed.

LPA informed the applicant that final approval for their license will be approved by CAB (Central Applications Bureau) in Sacramento. Applicant stated they understood.

Exit interview conducted and a copy of this report was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Alfonso Iniguez
NAME OF LICENSING PROGRAM ANALYST: Taylor Simerly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026
LIC809 (FAS) - (06/04)
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