<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606285
Report Date: 11/06/2025
Date Signed: 11/06/2025 11:55:49 AM

Document Has Been Signed on 11/06/2025 11:55 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:CENTURY GUEST HOME, THEFACILITY NUMBER:
300606285
ADMINISTRATOR/
DIRECTOR:		LIEZL DEOCAMPOFACILITY TYPE:
740
ADDRESS:14332 HOLT AVETELEPHONE:
(714) 544-7909
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 2DATE:
11/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Caregiver Simon SorianoTIME 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
On November 6, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Licensee (LI) Liezl Deocampo was notified via telephone but could not arrive to assist with today's inspection. LPA observed that Liezl Deocampo has a valid Administrator certificate which expires on September 14, 2027.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for three. The facility is a single story home with seven bedrooms, two of which are currently used by residents, five bathrooms, a living room, a dining room, a kitchen, a den, and an attached three car garage. LPA, accompanied by a care giving staff, conducted a tour of the interior portions of the facility. On today's visit, LPA observed two resident in care and two care giving staff present. LPA observed residents watching TV in their respective bedrooms. LPA inspected the two resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the resident bathrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 115.4 and 116.7 degrees Fahrenheit. LPA observed the staff bedrooms to be kept locked and inaccessible to residents in care.

LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the five burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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)
Page: 2 of 9
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: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285
VISIT DATE: 11/06/2025
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
26
27
28
29
30
31
32
LPA observed a fire extinguisher to be mounted on the wall by the kitchen and it was observed to be charged but last serviced on August 23, 2023. LPA tested the individual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility does not have any documented emergency disaster drills.

LPA observed the centrally stored medication to be kept in a locked closet by the kitchen. LPA observed the facility has a First Aid Kit stored in the closet and it had all the required components. LPA observed the facility has chemicals and toxins stored in the locked closet. LPA observed the door leading to the attached three car garage to be kept locked and inaccessible to residents in care. LPA observed the three car garage to be used for storage and laundry. PA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by a care giving staff, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates of the facility to be self latching and can be opened in an evacuation. There are no large bodies of water on the premises.

LPA reviewed the two resident files. LPA observed that there are no Reappraisals on file for Resident #1 (R1) or Resident #2 (R2). LPA reviewed the residents' medication and medication records. LPA observed the facility was providing three over the counter dietary supplements to R2 without a valid prescription. LPA reviewed three staff files. LPA observed that neither of the two care giving staff present during the visit, Staff #2 (S2) and Staff #3 (S3), had a valid CPR training card on file. LPA observed that there were no Health Screening reports on file for S2 or S3. LPA observed there was no documented initial training for S2 or S3.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-Ds. An exit interview was conducted with Licensee Liezl Deocampo via telephone. A copy of the report and Appeal Rights were provided to an authorized facility representative.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the facility was providing three over the counter dietary supplements to Resident #2 (R2) without a valid prescription.
POC Due Date: 11/07/2025
Plan of Correction
1
2
3
4
The Licensee stated that they will immediately stop providing the over the counter dietary supplements to R2 without a valid presription. The Licensee stated that they will either get prescriptions for the three dietary supplements, or permanently stop providing them. The Licensee stated that they will also conduct an in service training with staff regarding proper medication administration. The Licensee agreed to provide the training to LPA via email or fax by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that neither of the two care giving staff present during the visit, Staff #2 (S2) and Staff #3 (S3), had valid CPR training cards on file.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will have S2 and S3 complete CPR training. The LIcensee agreed to provide LPA the CPR training cards for S2 and S3 via email or fax by POC date.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that there was no Health Screening report on file for Staff #2 (S2) or Staff #3 (S3).
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will obtain Health Screening reports for S2 and S3. The Licensee agreed to provide the Health Screening reports for S2 and S3 to LPA via email or fax by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed there was no documented initial training on file for Staff #2 (S2) or Staff #3 (S3).
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will have S2 and S3 complete the required initial training. The Licensee agreed to provide the training records for S2 and S3 to LPA via email or fax by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that the facility does not have a See Something, Say Something poster (PUB 475) mounted in the facility.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will obtain a See Something, Say Something poster for the facility. The Licensee agreed to provide LPA proof of the poster via email or fax by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that there are no Reappraisals on file for Resident #1 (R1) or Resident #2 (R2).
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will complete the Reappraisals for R1 and R2. The Licensee agreed to provide LPA the Reappraisals for R1 and R2 via email or fax by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that there were no documented emergency disaster drills on file.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee stated that she will conduct an emergency disaster drill with all facility staff. The Licensee agreed to provide LPA proof of the emergency disaster training via email or fax by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 11/06/2025 11:55 AM - It Cannot Be Edited


Created By: Brandon Lopez On 11/06/2025 at 11:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the facility has one fire extinguisher mounted on the wall by the kitchen. LPA observed the fire extinguisher to be charged, however it has not been serviced since August 23, 2023.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Licensee said that she will have the fire extinguisher serviced. The Licensee agreed to provide LPA proof of service via email or fax by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 9 of 9