Inspection Reports for Epic Assistance Care Home I
26751 Carretas Dr, Mission Viejo, CA 92691, United States, CA, 92691
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and providing appropriate resident care. Several complaint investigations were conducted, with most allegations unsubstantiated except for issues related to COVID-19 safety protocols and failure to report a COVID-19 outbreak, both in 2023. Deficiencies primarily involved documentation problems such as outdated physician reports for residents with dementia, staff training records, and some environmental safety items like water temperature and fire extinguisher maintenance. The most recent inspection on May 1, 2025, cited three minor deficiencies but no severe issues or enforcement actions. Overall, the facility shows some improvement over time, especially with no deficiencies found in the latest complaint investigations.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
May 1, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found the facility generally clean and well-maintained with appropriate resident care and documentation. However, three Type B deficiencies were cited related to water temperature exceeding safe limits, lack of current CPR/First Aid certification for two staff members, and improper posting size of the RCFE Complaint poster.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| One faucet was found to deliver water at 138F which poses a potential health, safety or personal rights risk to persons in care. | Type B |
| Two staff members on duty during the visit did not possess a current CPR/First Aid certificate, posing a potential health, safety or personal rights risk to persons in care. | Type B |
| The RCFE Complaint poster was printed on an 8x10 sheet rather than the required 20x26 size, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Residents in care: 6
Facility capacity: 6
Perishable food supply: 2
Non-perishable food supply: 7
Water temperature: 138
Water temperature: 119
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Administrator | Facility administrator notified by phone and presented with report |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was an unannounced Required 1 Year Inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies issued. The environment, safety measures, emergency preparedness, and resident care conditions were all satisfactory.
Report Facts
Residents in care: 6
Staff on duty: 2
Facility capacity: 6
Water temperature: 114.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Administrator | Facility Administrator present during inspection and exit interview |
| Lianthon Harsan | Caregiver | Caregiver who accompanied Licensing Program Analyst during facility tour |
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 1
Capacity: 6
Deficiencies: 1
Jul 14, 2023
Visit Reason
The inspection visit was conducted as an unannounced investigation of deficiencies related to allegations in complaint reference #22-AS-20230217143103.
Findings
One deficiency was cited for failure to report a COVID-19 outbreak involving multiple staff members and one resident in November 2022 to the Department as required by regulation.
Complaint Details
The visit was triggered by a complaint alleging failure to report a COVID-19 outbreak. The deficiency was substantiated based on interviews and record review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report epidemic outbreaks within 24 hours to the licensing agency as required by California Code of Regulations Section 87211(a)(2). | Type B |
Report Facts
Capacity: 6
Census: 1
Deficiencies cited: 1
Plan of Correction Due Date: Jul 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Administrator | Facility administrator involved in the inspection |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and documented deficiencies |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 1
Capacity: 6
Deficiencies: 1
Jul 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-02-17 regarding multiple allegations including questionable death, unauthorized alcohol given to a resident, failure to address and notify changes in resident condition, lack of dignity and supervision, and COVID-19 safety protocol violations.
Findings
The investigation found all allegations except one to be unfounded or unsubstantiated. The allegation that staff did not follow proper COVID-19 safety protocols was substantiated, with staff members who tested positive kept on active duty without reporting a critical staffing shortage. Other allegations including questionable death, unauthorized alcohol provision, failure to notify or address resident condition changes, lack of dignity, and inadequate supervision were found to be without reasonable basis.
Complaint Details
The complaint investigation was triggered by multiple allegations including questionable death, unauthorized alcohol given to a resident, failure to address and notify changes in resident condition, lack of dignity and supervision, and failure to follow COVID-19 safety protocols. The investigation concluded that all allegations except the COVID-19 safety protocol violation were unfounded or unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to separate and care for residents whose illness requires separation, including quarantine or isolation, as staff members with confirmed COVID-19 diagnosis continued providing care without reporting a critical staffing shortage. | Type A |
Report Facts
Facility capacity: 6
Census: 1
Deficiency due date: Jul 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
| Liza Mesdjian | Administrator | Facility administrator involved in the investigation |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Mar 30, 2023
Visit Reason
An unannounced Required – 1 Year Annual inspection was conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be clean, in good repair, and well maintained with adequate safety measures. However, deficiencies were cited related to outdated physician reports for residents with dementia and lack of documented required staff training.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Three out of six Physician's Reports for residents with confirmed Dementia diagnosis were outdated by up to two years. | Type B |
| Two out of two staff files lacked documentation of required training and orientation. | Type B |
Report Facts
Residents present: 6
Residents receiving Hospice care: 4
Facility capacity: 6
Plan of Correction Due Date: Apr 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Martinez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Armando J Lucero | Licensing Program Manager | Supervisor overseeing the inspection |
| Liza Mesdjian | Administrator | Facility administrator present during inspection |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 2
Feb 22, 2023
Visit Reason
The visit was an unannounced inspection conducted to document deficiencies observed during the initial investigation of allegations in complaint reference #22-AS-20230217143103.
Findings
Two deficiencies were cited: the fire extinguisher maintenance was outdated by six months, and four out of five physician reports for residents with confirmed dementia diagnoses were outdated by up to two years. Additionally, a technical violation advisory was issued for admitting a resident with a Stage 3 dermal ulcer without an exemption request, and a technical assistance advisory was issued for outdated certificates posted in the facility.
Complaint Details
The visit was triggered by a complaint investigation referenced as #22-AS-20230217143103.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Fire extinguisher maintenance was out of date since August 2022, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
| Four resident records included outdated physician reports for residents with confirmed dementia diagnoses, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Census: 5
Total Capacity: 6
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Administrator | Administrator involved in the inspection and named in findings |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection and documented findings |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 0
Apr 28, 2022
Visit Reason
The visit was a scheduled follow-up for the purpose of completing the pre-licensing for the facility.
Findings
The Licensing Program Analyst observed that the facility had installed a fireplace screen and nightlights in bedrooms, hallways, and kitchen to secure nighttime circulation. All elements verified appeared to be in compliance and the facility was ready to be licensed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simona Aziza | administrator | Accompanied Licensing Program Analyst during the facility tour and was involved in the inspection. |
Inspection Report
Original Licensing
Census: 6
Capacity: 6
Deficiencies: 4
Apr 12, 2022
Visit Reason
The visit was conducted for the purpose of pre-licensing verifications required for a change of ownership at the facility.
Findings
The facility was toured and found generally well maintained with adequate safety features and supplies; however, several items needed correction before licensing, including securing cleaning supplies, installing a screen in front of the fireplace, adding night lights, and securing medications and toxic substances in the staff bedroom.
Deficiencies (4)
| Description |
|---|
| Two missing locks needed to secure the cabinets where cleaning supplies are stored in the laundry room. |
| A screen needed to be installed in front of the dining room fireplace. |
| Night lights needed to be installed in the bedrooms and hallways to allow secure access to the bathrooms at night. |
| Supplements, medication, and potential toxic substances stored in the staff bedroom needed to be secured either within a cabinet or by allowing access to the room to be locked by staff. |
Report Facts
Capacity: 6
Census: 6
Hot water temperature: 106
Hot water temperature: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Licensee | Prospective licensee met during the inspection and involved in the pre-licensing process |
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Original Licensing
Census: 6
Capacity: 6
Deficiencies: 0
Feb 17, 2022
Visit Reason
The visit was conducted as an original licensing evaluation for the EPIC Assistance Care Home facility, including a telephone interview to verify the applicant/administrator's understanding of California Code Title 22 Regulations and readiness for licensing.
Findings
The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liza Mesdjian | Administrator & Corporate Board Member | Named as applicant/administrator participating in the licensing evaluation and interview. |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation. |
| Bailey Humes | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation and interview. |
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