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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000629
Report Date: 06/13/2025
Date Signed: 06/13/2025 02:00:52 PM

Document Has Been Signed on 06/13/2025 02:00 PM - 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:CUDDLE CARE HOMEFACILITY NUMBER:
306000629
ADMINISTRATOR/
DIRECTOR:		NELLIE MAE CAUDLEFACILITY TYPE:
740
ADDRESS:416 E. CHESTNUT AVE.TELEPHONE:
(714) 282-8951
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 5CENSUS: 2DATE:
06/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nellie Mai Caudle AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) William Vanegas conducted an unannounced inspection for the purposes of completing an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Nellie Mai Caudle. LPA Vanegas explained the purpose of the inspection and being a tour of the facility

LPA Vanegas observed the following. This is a one storied house with four bedrooms, and two bathrooms. There is an attached two car garage, and a large backyard in the facility. LPA Vanegas observed the kitchen area to be clean and free of any debris. LPA Vanegas observed a seven day supply of non-perishable foods, and a two day supply of perishable foods LPA Vanegas also observed a sufficient amount of emergency water.

LPA Vanegas observed an electric stove, refrigerator, microwave, dishwasher, washer, and dryer that all appeared in good repair, and tested operational. LPA Vanegas observed all fire extinguishers to be fully charge and up to date. LPA Vanegas observed smoke and carbon monoxide detectors to be in good repair and operational.

LPA Vanegas observed all resident rooms to be clean and free of any debris. LPA Vanegas observed all resident rooms to have required furnishings such as chest drawers, a bed, clean linens in good repair; meaning no strains or tears, enough storage space to store personal belongings, and a reading lamp.
LPA Vanegas observed resident bathrooms to have all required furnishings such as a shower chair, slip resistant floor matts, and grab bars. Water faucets and toilets tested operational. Water temperature tested between 112.8 and 113.0 degrees. CONTINUED ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2025
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 6
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CUDDLE CARE HOME
FACILITY NUMBER: 306000629
VISIT DATE: 06/13/2025
NARRATIVE
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LPA Vanegas observed the out side of the facility to have a large back yard, and a pool that is fully fenced. The fence measured to be 4ft and 9in. The gaps in between the fence measured to be 5in apart. The pool gate was locked and when open the door swings into the pool area. LPA Vanegas observed some items that are to be discarded in the backyard, and along the exit routes. An advisory note was issued to discard of these items as soon as possible. Side doors are self latching and unlocked

LPA Vanegas observed first aid kit to have all required items. LPA Vanegas observed one staff files, and two resident files all resident files consisted of all required forms. However staff on duty was unable to present their first aid and cpr training, and the annual training was not provided for review.LPA Vanegas observed medications with AD and per LPA Vanegas review all medications are being documented correctly and being administered per physicians orders.

Based on observations made during today's inspection no deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with AD Nellie Mai Caudle, and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/13/2025 02:00 PM - It Cannot Be Edited


Created By: William Vanegas On 06/13/2025 at 01:33 PM
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: CUDDLE CARE HOME
FACILITY NUMBER: 306000629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on record review, the licensee did not comply with the section cited above in two out of two staff did not have proper CPR certification available for review which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Administrator will provide proof of the CPR certification and send proof to LPA via email by P.O.C Due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/13/2025 02:00 PM - It Cannot Be Edited


Created By: William Vanegas On 06/13/2025 at 01:33 PM
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: CUDDLE CARE HOME
FACILITY NUMBER: 306000629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of two staff not having training completed or documented which poses a potential health risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Administrator will send proof of training completed to LPA Via email before P.O.C due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2025


LIC809 (FAS) - (06/04)
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