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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004198
Report Date: 09/10/2025
Date Signed: 09/12/2025 03:54:55 PM

Document Has Been Signed on 09/12/2025 03:54 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:VERSA-CARE HOME IFACILITY NUMBER:
306004198
ADMINISTRATOR/
DIRECTOR:		CHERRY AGUILAFACILITY TYPE:
740
ADDRESS:1576 SPRUCE UNIT ATELEPHONE:
(714) 646-9217
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
09/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Cherry Aguila - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On September 3, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Jerome Macasaquit and explained the purpose of the visit. Administrator (AD) Cherry Aquila arrived a short time later and was present throughout the inspection visit.

The facility is licensed to operate for six (6) non-ambulatory residents with a Hospice waiver for six (6). The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) resident bathroom, one (1) staff bathroom, living room area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

LPA Bentley toured inside and outside of the physical plant with CG Macasaquit. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be operational and clutter free. The water temperature measured at 117.1 degrees F to 117.5 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Bentley 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 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 safety drills are being conducted quarterly. First aid kit is maintained and contains all the necessary elements.

Continued on LIC 809-C...

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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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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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
VISIT DATE: 09/10/2025
NARRATIVE
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During the visit, LPA Bentley observed the facility's smoke detectors and carbon monoxide detectors were operational. A working telephone (714-646-9217) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were observed. The facility has a (1) fire extinguisher that was charged, mounted, and serviced on January 14, 2025. Liability Insurance is effective 7/1/2025 and expires on 7/1/2026.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), and medication and medication administration review. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided.

(Continued on LIC 809-C)

Based on today’s observations deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Cherry Avila.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2025 03:54 PM - It Cannot Be Edited


Created By: Eboni Bentley On 09/10/2025 at 05:24 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: VERSA-CARE HOME I
FACILITY NUMBER: 306004198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8703(2)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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, which poses a potential health and safety risk to persons in care. LPA observed unsanitary conditions in the hallways where spider webs and filters needed to be clean and a missing mirror door and bath towel rack in staff bathroom. Liighting in three out of four resident rooms and resident bathroom were in need of repair. LPA also observed a dirty toilet, shower, and bathmat in unsanitary condition.
POC Due Date: 09/17/2025
Plan of Correction
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Administrator will have both bathrooms a deep cleaned, clean all areas in hallway, check and replace all lighting throughout the facility, and replace mirror door and bath towel rack in staff bathroom. Administrator will email LPA Bentley photos of the repaired/replaced items, cleaned bathrooms and hallways by POC due date.
Type B
Section Cited
CCR
87412(a)(11)
(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
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above in two of two staff records, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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Administrator stated health screening will be obtained for staff and proof provided to LPA via email 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2025


LIC809 (FAS) - (06/04)
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