306004275-1-30-2026-22-AS-SHAN-DQTMWZ-20260130085910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004275
Report Date: 01/30/2026
Date Signed: 01/30/2026 08:59:36 AM

Document Has Been Signed on 01/30/2026 08:59 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:	CHEERFUL HEART HOME V		FACILITY NUMBER:	306004275
ADMINISTRATOR/ DIRECTOR:	ANA SANDRU		FACILITY TYPE:	740
ADDRESS:	10722 ALBANY CIRCLE		TELEPHONE:	(714) 726-6525
CITY:	VILLA PARK	STATE: CA	ZIP CODE:	92861
CAPACITY: 6		CENSUS: 6	DATE:	01/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:23 AM
MET WITH:	CareStaff Sara		TIME VISIT/ INSPECTION COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to complete the required one-year inspection. Upon arrival, the LPA was greeted and granted entry by care staff. The Administrator (AD), Ana Sandru, was notified by caregivers of the visit and arrived shortly after the LPA’s arrival. During the inspection, the LPA toured the facility’s physical plant, both inside and outside. The facility is a single-story home with seven bedrooms and four restrooms. One bedroom is designated for staff use, and six bedrooms are designated for resident use. At the time of the visit, there were two staff members on duty and six residents in care; two of the six residents were currently hospitalized. The LPA and S1 tested the smoke detectors and carbon monoxide detectors in the common areas and resident bedrooms, and all were operational. Resident bedrooms were observed to have the required furniture, including adequate bed linens and sufficient closet and/or drawer space to accommodate each resident. The LPA observed a fire extinguisher mounted in the kitchen area with a purchase date of June 16, 2025. Record review reflected a fire drill was conducted on November 10, 2025. The LPA also observed that sharps and knives were secured in a locked kitchen drawer. The LPA observed the facility maintained a two-day supply of perishable food and a seven-day supply of nonperishable food and water. All kitchen appliances were observed to be operational during the visit. Restroom toilets and water faucets were observed to be operational, and grab bars were secure. Showers were observed to be free of mold and mildew. The hot water temperature was measured between 111.6 degrees Fahrenheit and 112.0 degrees Fahrenheit. The LPA and AD toured the backyard and observed a shaded seating area available for resident use. The LPA reviewed three resident files and three staff files and observed the required documentation was present. Based on observations and record review completed during this inspection, no deficiencies were cited pursuant to Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to facility staff at the conclusion of the inspection.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

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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