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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001920
Report Date: 03/19/2026
Date Signed: 03/19/2026 05:03:03 PM

Document Has Been Signed on 03/19/2026 05:03 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:ARC FACILITY AT RICHMANFACILITY NUMBER:
306001920
ADMINISTRATOR/
DIRECTOR:		MIKE ADAMSFACILITY TYPE:
740
ADDRESS:1037 N RICHMAN AVE.TELEPHONE:
(714) 870-5820
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 4DATE:
03/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Caregiver- Lourdes ManunayTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On March 19, 2026, at 1:15PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Lourdes Manunay. Around 1:40 PM, LPA Kim spoke with Administrator (ADMIN) Mike Adams over the phone and explained the purpose of the visit. ADMIN Adams stated they could not attend today’s visit because they were out of the country and that CG Manunay could sign on behalf of the facility. LPA also spoke with ADMIN Adams about past due licensing fees and a current balance of $4947.00. ADMIN stated they will pay the Licensing Fee, but did not provide when.

The facility is licensed to operate for six (6) nonambulatory residents and has a hospice waiver for five (5) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) staff bedroom, three (3) bathrooms, living area, foyer, dining area, kitchen, outdoor covered patio, and a detached two car garage. The prior year, there was a walk-in closet next to the kitchen, but it was changed to be a second staff room. The facility sketch shows these two staff bedrooms were once one big staff room and that wall was not part of the original sketch.
LPA Kim toured inside and outside of the physical plant with CG Manunay. There were no bodies of water and no physical obstructions in the passageways. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be clean and operational. Resident bathrooms hot water temperature measured between 98.4 degrees F to 100.0 degrees F. A comfortable temperature of 78 degrees F was maintained in the facility.
Evaluation Report Continues on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ARC FACILITY AT RICHMAN
FACILITY NUMBER: 306001920
VISIT DATE: 03/19/2026
NARRATIVE
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LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in staff room #2. The facility has one (1) fire extinguisher that is charged and was not mounted in the kitchen. There is no service inspection date or receipt of purchase for the fire extinguisher. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A working telephone (714-870-5820) remains available.

LPA Kim conducted an audit of resident files (R1-R4) and staff files (S1-S3). LPA observed R1's Appraisal Needs and Service plan was not signed and dated, and R2's Appraisal Needs and Service plan was last done on December 18, 2021. LPA observed R3 did not have a completed Physician's Report. There is a note that indicates that Kaiser refused to fill out the form. LPA did not observed 2026 staff annual training for S1-S2. The following observations were made: LPA observed there are two staff rooms at the facility, but the original facility sketch only shows one staff room. There is a wall added that was not reflected in the original sketch on file. The Fire extinguisher is not mounted and does not have an inspection service date or receipt. LPA Kim will address all of this in a subsequent visit.
Due to time constraint a continuation of this inspection will be conducted at a later date. LPA will inspect all smoke and carbon monoxide detector, conduct an audit of the medication and medication administration record, staff interviews, resident interviews, a review of the evidence of liability insurance, audit of the emergency drill log, and audit of the first aid kit will be conducted.
Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed R1's Appraisal Needs and Service plan was not signed and dated, and R2's Appraisal Needs and Service plan was last done on December 18, 2021. LPA observed R3 did not have a completed Physician's Report. There is a note that indicates that Kaiser refused to fill out the form. LPA did not observe 2026 Staff annual training for S1-S2. Resident bathrooms hot water temperature measured between 98.4 degrees F to 100.0 degrees F. The facility has a past due annual licensing fees for $4947.00 that has not been paid as of March 19, 2026.

An exit interview was conducted, and a copy of this report, LIC811, and LIC809D, and appeal rights were provided to Caregiver Lourdes Manunay.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/19/2026 05:03 PM - It Cannot Be Edited


Created By: Edward Kim On 03/19/2026 at 04:08 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: ARC FACILITY AT RICHMAN
FACILITY NUMBER: 306001920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident bathrooms measured between 98.2 degrees F to 100.0 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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Licensee states they will send video and photo proof that all resident bathrooms are compliant and measuring between 105.0 degrees F to 120.0 degrees F to CCLD via email to edward.kim@dss.ca.gov by POC due date March 20, 2026.
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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2026 05:03 PM - It Cannot Be Edited


Created By: Edward Kim On 03/19/2026 at 04:08 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: ARC FACILITY AT RICHMAN
FACILITY NUMBER: 306001920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of three staff. LPA observed S1's and S2's 2026 annual training was missing and not available during the visit. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee stated they will send 2026 annual training for S1 and S2 to CCLD via email to edward.kim@dss.ca.gov by POC due date April, 3, 2026.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed R3 did not have a completed Medical Assessment. There is a note that indicates that Kaiser refused to fill out the form. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee stated they will send R3's physician report to CCLD via email to edward.kim@dss.ca.gov by POC due date April 3, 2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/19/2026 05:03 PM - It Cannot Be Edited


Created By: Edward Kim On 03/19/2026 at 04:08 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: ARC FACILITY AT RICHMAN
FACILITY NUMBER: 306001920

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026

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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed R1's Appraisal Needs and Service plan was not signed and dated, and R2's Appraisal Needs and Service plan was last done on December 18, 2021. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee states they will send a completed and updated Appraisal Needs and Service Plan for R1 and R2 to CCLD via email to edward.kim@dss.ca.gov by POC due date April 3, 2026.
Type B
Section Cited
CCR
87156(a)
81756 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed that the facility has not paid their annual fees and have a balance due for $4947.00. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
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Licensee states they will pay the $4947.00 balance and provide proof of payment to CCLD via email to edward.kim@dss.ca.gov by POC due date March 26, 2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
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