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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004176
Report Date: 08/04/2025
Date Signed: 08/04/2025 04:37:51 PM

Document Has Been Signed on 08/04/2025 04:37 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:SAM'S HOMECAREFACILITY NUMBER:
306004176
ADMINISTRATOR/
DIRECTOR:		JUHAYNA DIAZFACILITY TYPE:
740
ADDRESS:18900 SEABISCUIT RUNTELEPHONE:
(714) 312-0054
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 4DATE:
08/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:House Manager- Rosallie GabrielTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On August 4, 2025, at 1:30 PM, 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 met with House Manager (HM) Rosallie Gabriel. A phone call was attempted to Administrator (AD) Juhayna Diaz. ADMIN Diaz did not respond and who could not attend today's visit. HM Gabriel signed on behalf of the facility because ADMIN Diaz was absent from August 1, 2025, to August 4, 2025..

The facility is licensed to operate for six (6) non-ambulatory residents and have a hospice waiver for four (4) residents. The facility is a two-story building located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, five (5) staff bedrooms, six (6) bathrooms, living room, family area, dining room, office, kitchen, attached 2-car garage, and 2 outside covered patio areas.

LPA Kim toured indoor and outdoor of the physical plant with HM Gabriel. There are no obstructions or bodies of water on the premises. 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. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Staff Room 1, Staff Room 2, Staff Room 3, Staff Room 4, and Staff Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. Bathroom water temperature measured between 107.6 degrees F and 108.1 degrees F. A comfortable temperature of 76 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: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAM'S HOMECARE
FACILITY NUMBER: 306004176
VISIT DATE: 08/04/2025
NARRATIVE
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LPA Kim observed the facility to be sanitary and 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. LPA observed the left side burners were covered and the knobs had child safety locks on them. The Licensee was not present for the LPA to test if the burners were operable. Emergency food, water, and supplies are stored in the kitchen pantry and in the garage.

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). The facility conducts Fire/Safety Drills quarterly and was last conducted on June 1, 2025. A working telephone (714-312-0054) remains available. Smoke detectors and carbon monoxide detectors were operable. LPA audited resident files (R1-R4). LPA observed appraisal from R1 dated 11/25/2023, R2 dated 3/24/2024, and R4 did not have any appraisal on file. LPA observed medical assessment from R1 dated 11/29/2023 diagnosed with dementia, and R2 dated 6/26/2023 who is diagnosed with dementia.

Due to time constraints a continuation of this inspection will be conducted at a later date. LPA Kim will: 1) conduct record review for staff, 2) Conduct interviews with staff and residents, 3) Inspect First Aid Kit, 4) inspect device with internet access dedicated residents, and 5) conduct a medication review at a later date.

Based on today’s visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed appraisal from R1 dated 11/25/2023, R2 dated 3/24/2024, and R4 did not have any appraisal on file. LPA observed the auditory devices for the front entrance, vacant resident room, and backdoor exit were not in working order during the visit. Technical violations were assessed during the visit. LPA observed medical assessment from R1 dated 11/29/2023, and R2 dated 6/26/2023. LPA observed the left side burners covered and with child proof safety locks at the knobs. LPA observed the LIC308 does not designate the house manager when Administrator is absent.

An exit interview was conducted and a copy of this report and appeal rights were provided to House Manager Rosallie Gabriel.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2025 04:37 PM - It Cannot Be Edited


Created By: Edward Kim On 08/04/2025 at 03:58 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: SAM'S HOMECARE
FACILITY NUMBER: 306004176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2025

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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of four residents. LPA observed appraisal from R1 dated 11/25/2023, R2 dated 3/24/2024, and R4 did not have any appraisal on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee stated they will have recent and completed Appraisal for R1, R2, and R4 and send proof of completed forms to CCLD via email to edward.kim@dss.ca.gov by POC due date August 18, 2025.
Type B
Section Cited
CCR
87705(d)
87705(d)The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section

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 the auditory device in the entrance, vacant resident room, and backdoor exit not in working order. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee stated they will fix the auditory devices for the entrance, backyard exit, and vacant resident room and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date August 18, 2025.
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: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
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