Pacific Shores of Mission Viejo

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA arrived at facility and was greeted and granted entry into the facility by caregiver. LPA explained the reason for the visit. Administrator (AD) Amy Zuehl arrived shortly to assist with the visit. Facility is licensed for six non-ambulatory residents; one may be bedridden with a hospice waiver for six. Currently there are six residents, of which four are on hospice during today's visit. LPA accompanied began the tour of the inside and outside of the facility. The home consists of five resident bedrooms, a staff room, two bathrooms, living room, family room, dining room, kitchen, laundry room and an attached garage. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the two additional refrigerators in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in the hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA observed the first aid kit and advised Administrator to obtain a current version of the first aid manual. LPA inspected the facility bathrooms (2) and LPA measured the hot water temperature which measured 105.2 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient Continued on LIC809-C hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which have sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors/carbon monoxide detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment in the front yard as well as the backyard of the facility. LPA observed a fire extinguisher with service date of May 1, 2026, charged and mounted in the kitchen. Fire drills are conducted and last drill was conducted on May 26, 2025. LPA began reviewing records. LPA reviewed three resident records. All the required documentation was present and reviewed in the residents’ files. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated with the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:41 AM, LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. Administrator (AD) Amy Zuehl arrived shortly to assist with the visit. Facility is licensed for six non-ambulatory residents; one may be bedridden with a hospice waiver for six. Currently there are six residents, of which one is on hospice during today's visit. LPA Tea reviewed six resident files and two staff files. Resident files and staff files contained all required documentation. Administrator certificate expires on August 03, 2025. LPA reminded AD Zuehl that her certificate is going to expire soon. She acknowledged that she has completed all course work and submitted everything already. LPA Tea along with AD Zuehl toured the facility at 9:50 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of five resident bedrooms, a staff room, two bathrooms, living room, family room, dining room, kitchen, laundry room and an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.6 F degrees and 108.5 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, and doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply were checked and adequately stocked at time of visit. LPA observed sharps locked underneath the kitchen sink. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink and the laundry room. The fire Annual inspection continued on LIC809-C extinguisher in the kitchen is fully charged. The facility’s last disaster drill was conducted in February 15, 2025. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and there are two exit gates on both sides of the house that are self-latching and operational. The backyard has a shaded patio area for clients to sit. There are various plants and fruit trees in the backyard garden, sometimes the residents come outside to enjoy the weather. LPA observed emergency supplies, food and water in the garage. LPA noted that the facility’s emergency water was really low. LPA reminded AD Zuehl there needs to be enough for residents and staff in case of emergency. Activities are based on resident’s personal preference or health condition. Facility provides activities like physical therapy and exercises. At the time of the visit, LPA observed residents eating breakfast and watching television. LPA then reviewed medication storage and administration. Medications are stored in a locked closet in the facility. Medications are being administered per physicians order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility and a copy of this report LIC809, 809-C, LIC858, LIC859, LIC9102 was read and provided to the facility.the state’s words, verbatim · CDSS document, Jun 12, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA Cho was greeted and granted entry by Administrator (Admin) Benigno Bulanadi. Licensee/Administrator Herminia Zuehl arrived shortly. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory in which one (1) may be bedridden and maintains a hospice waiver for six (6). There is one (1) bedridden resident and three (3) residents under hospice care on today's date. LPA toured the interior and exterior portions of the facility. There are a total of five resident bedrooms and one resident bathroom. There is one staff bedroom and bathroom. LPA observed the facility to be clean, sanitary, and operational. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed resident bathroom to be in good repair, provided with handrails, and a non-skid floor mat. The hot water temperature measured at 109.4 degrees Fahrenheit in the resident bathroom and 112.4 in the staff/guest bathroom. Facility met the two day perishable and seven day non-perishable food supplies. LPA observed medications, toxins, and sharps were inaccessible to the residents. The fire extinguisher was serviced on April 14, 2024. LPA observed clutter in the garage which is a safety hazard and administrators were advised to clear the clutter. For the exterior portion, facility had sufficient seating and shading. The exit doors were self-closing and self-latching. LPA observed the emergency disaster supplies including food/water. LPA observed the required "See Something, Say Something' (PUB475) poster in the required size. Administrator's Certificate for Beningno Bulanadi expires on July 17, 2025. LPA conducted an audit of six residents' files and two staff files. A discrepancy was observed with one resident file as no proof of TB testing was provided for Resident #1 (R1). No discrepancies for the staff files. Resident interviews were conducted however LPA could not meet with the caregivers as one staff was preparing dinner while the other was assisting residents. Medications were audited. No discrepancies noted. LPA consulted the following: to clear the clutter in the garage in order to adhere to the regulations by the State Fire Marshal, to obtain a Tuberculosis test result for R1, and to pay the annual licensing fee that was due on June 10, 2024. Based on the observations made during today's visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See the attached LIC9099D. An exit interview was conducted with Administrators Herminia Zuehl and Beningo Bulanadi, and a copy of this report including the LIC809C, LIC809D, LIC811s, and the appeal rights were provided during this visit.the state’s words, verbatim · CDSS document, Jun 19, 2024