197610863-12-2-2025-31-AS-ERIS-DNYR5J-20251202114313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610863
Report Date: 12/02/2025
Date Signed: 12/02/2025 11:43:29 AM

Document Has Been Signed on 12/02/2025 11:43 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AQUAMARINE RETIREMENT HOME CARE		FACILITY NUMBER:	197610863
ADMINISTRATOR/ DIRECTOR:	TIU, GLENNARD		FACILITY TYPE:	740
ADDRESS:	6523 W AVENUE L7		TELEPHONE:	(661) 418-0715
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	12/02/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:19 AM
MET WITH:	Glennard Tiu - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the applicant representative/administrator, Glennard Tiu. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 07/11/2025. This is a change in ownership (CHOW) application. The current census for active license is six (6). A fire clearance was approved on 09/03/2025 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). At entrance LPA observed required postings by the front door and a sign in sheet for visitors. A tour of the physical plant was initiated at approximately 9:25 a.m., and the following was observed: Bedrooms: There are six (06) total private bedrooms designated for residents use. Per STD 850, rooms #2 is cleared for one (01) bedridden resident. Bedrooms designated for resident use have appropriate furniture with sufficient lighting and storage space. LPA observed functional auditory alarms on all exit doors. LPA observed a fully charged fire extinguisher last serviced on 06/20/2025 by bedroom #4. Kitchen: The kitchen is equipped with a refrigerator, stove, oven, dishwasher and microwave. The facility has a sufficient amount of two day perishable and seven day non perishable supply of food. The facility has dishware and cook ware for the capacity of the facility. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AQUAMARINE RETIREMENT HOME CARE	FACILITY NUMBER: 197610863
	VISIT DATE: 12/02/2025

NARRATIVE

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Common Areas: Furniture such as the dining table, chairs and couches were observed in good repair. Both living room and dining room have sufficient space and lighting. LPA observed a television and games in the living room. A fireplace was also observed not in use, secured with a screen. No tripping hazards observed. LPA observed a fully charged fire extinguisher last serviced on 06/20/2025 by the dining table.

Bathrooms: The facility has three (03) bathrooms. Two (02) bathrooms are designated for resident use of which one (01) is located in a resident bedroom for private use. Bathrooms were observed to have proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured and was within regulation.

Laundry/Garage: The laundry room is accessible to residents and equipped with a washer and dryer. LPA observed detergent, and cleaning supplies are kept locked in a laundry room closet. Entrance to the attached garage is through the laundry room. In the garage LPA observed a freezer and facility supplies.

Resident/Staff Records: Residents' medication was observed locked in a kitchen cabinet. Resident, staff, facility records and a fully supplied first aid kit with manual are stored in a kitchen cabinet. LPA reviewed the administrator file and six (06) of six (06) resident records.

Backyard: LPA observed a fenced in backyard with appropriate outdoor furniture. No bodies of water on the premises. Exits and passageways were clear from obstructions.

The carbon monoxide detector was observed on a wall by the living room, functioning. Smoke detectors are located throughout the facility. LPA observed smoke detectors to be functioning properly.

Component III was held with applicant representative/administrator. Pre-Licensing is complete and no deficiencies were observed. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted. A copy of this report was signed and provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC809 (FAS) - (06/04)

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