Pacific Shores of Lake Forest

Type of visit: Required - 1 Year

On August 4, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (ADMIN) Hermina "Amy" Zuehl and explained the purpose of the visit. The facility is licensed to have a capacity of six (6) nonambulatory residents, of which one (1) is bedridden and a hospice waiver for six (6) residents. LPA Kim observed the following. The facility is a one-story house with an attached 2-car garage with five (5) resident bedrooms, one (1) staff bedroom, four bathrooms, dining room, a kitchen, a living room, and outdoor shaded area. LPA Kim toured inside and outside of the physical plant. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 116.7 degrees F and 118.0 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water and emergency supplies are stored in the garage. All mandated inspection control posters were posted. The facility has smoke detectors and carbon monoxide detectors that were operable. The Certificate of Liability Insurance is effective from August 7, 2025, to August 7, 2026. The facility conducts Fire/Safety Drills quarterly and was last conducted on May 26, 2026. One (1) fire extinguisher is mounted in the facility in the kitchen and was last serviced on April 1, 2026. A working telephone Facility phone number (949-716-8903) and a computer dedicated to the residents both remain available. First Aid Kit contained all the necessary elements. LPA Kim conducted an audit of six (6) residents (R1-R6) files, and five (5) staff (S1-S5) personnel files, and medication and medication administration records that were all in order and complete. There are no deficiencies cited during the visit. An exit interview was conducted, and a copy of this report was provided to Administrator Hermina "Amy" Zuehl.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. For this visit, there are 5 residents in care, of which 3 are on hospice. For this visit, LPA Rodriguez met with facility administrator (AD) - Hermina "Amy" Zuehl. LPA Rodriguez observed the facility administrator (AD) certificate for Hermina Zuehl which expires on 8/3/25. LPA Rodriguez observed that the PUB475 "See Something, Say Something" poster was posted at the entrance of the facility. The facility has a total of 5 bedrooms, of which all 4 are private resident rooms and 1 shared resident room. LPA Rodriguez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Facility was observed to have 4 bathrooms. Bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Hot water was measured at 114.7 degrees Fahrenheit. LPA Rodriguez observed that the facility had a two-day supply of perishables and a seven-day supply of non-perishable food. LPA Rodriguez observed hallways were free of obstructions. For the exterior portion, LPA Rodriguez observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed. LPA Rodriguez observed that the facility has fire extinguishers that were charged, mounted and located in the kitchen with a maintenance tag dated for 2025. Sharp items, and medications were observed to be locked and inaccessible to residents in care. Cleaning supplies were observed to be locked in the garage and in the cabinets. LPA Rodriguez observed the Emergency and Disaster Plan posted in the kitchen. Facility has emergency supplies located in the kitchen pantry. LPA Rodriguez reviewed all five resident files. LPA Rodriguez reviewed staff files, and observed that current staff members are cleared and associated to the facility. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. An exit interview was conducted with AD Zuehl. A copy of this report was explained and provided during the visit.the state’s words, verbatim · CDSS document, Jul 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Benigno Bulanadi and explained the reason for the visit. Benigno Bulanadi's Administrator's certificate expires on July 17, 2025. The facility is a one story home with 5 bedrooms, staff room, 4 bathrooms, kitchen, laundry room, dining room, living room with a fireplace, family room, caregiver room and a 2 car garage. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the fireplace in the living room is not screened. The Administrator reported that fireplace is never used. LPA and the Administrator toured the facility. LPA observed all 5 resident rooms had the required furnishings and bed linens. Smoke detectors/carbon monoxide detectors tested operational. All 4 bathrooms are clean and operational. Hot water measured 108.5 to 109.2 degrees Fahrenheit in all bathrooms. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. The garage is kept locked and used for storage. No obstacles or hazards observed inside of the facility. LPA and the Administrator toured the backyard. LPA observed old bed rails and tiles stored on the North side of the house that does not have the exit gate. LPA observed there are two shaded seating areas in the backyard. No bodies of water observed. LPA observed the outside fireplace is not screened. The side of the house with the exit gate (South side) is free of obstacles and hazards. The exit gate is operational and self closing. LPA reviewed 6 residents records and medications, no discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed, both staff members had the required training including first/CPR training. LPA inspected the first aid kit. The first aid kit has all the required elements. The last facility emergency drill was conducted on May 31, 2024. LPA observed the facility has internet service (WiFi) but does not have a dedicated internet device for residents. No deficiencies are being cited as a result of this visit. Three (3) technical violations issued (LIC 9102). An exit interview was conducted and a copy of the report provided along with the technical violations.the state’s words, verbatim · CDSS document, Jul 10, 2024

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.