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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004379
Report Date: 01/23/2026
Date Signed: 01/23/2026 01:08:26 PM

Document Has Been Signed on 01/23/2026 01:08 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:MOMS AND DADSFACILITY NUMBER:
306004379
ADMINISTRATOR/
DIRECTOR:		ACE JACER EDORA TABLANGFACILITY TYPE:
740
ADDRESS:6177 NORSTADT WAYTELEPHONE:
(714) 883-3140
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
01/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Edora TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


The facility is a single level structure and licensed for six resident (5 non-ambulatory), of which one may be bedridden. As of today, the facility has three residents admitted to the facility. All of the residents were present during the visit. There’s a total of 5 bedrooms (4 resident & 1 staff) and 2 bathrooms areas for residents. There’s a living room space, a dining space, backyard and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water was measured at 116.6 degrees F in both restrooms. Kitchen: 5 of 5 burners are operational on the gas stove. Sharps are kept locked in a cabinet under the counter. Cleaning chemicals are stored in a locked cabinet below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

Resident & Staff Files: Resident and staff files are stored in the locked filing cabinet in the garage.
File Review: 3 of 3 resident files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in the locked medication cabinet in the kitchen. A first aid kit was also observed mounted on the wall in the dining room.


Medication Review: 3 of 3 resident medications were reviewed during the visit.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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 5
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: MOMS AND DADS
FACILITY NUMBER: 306004379
VISIT DATE: 01/23/2026
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Linens & Hygiene Supplies: Hygiene and incontinent care supplies were observed locked cabinets in the main hallway. Plenty of additional linens were observed in the main hallway cabinets.

Garage Area: The garage is organized and walkways are free of obstruction. There’s an office area with a desk and computer for staff. Emergency water was observed and a laundry with a washer and dryer. Soaps and cleaning solutions are in a cabinet above the washer and dryer.
Backyard/Exterior: The backyard has a shaded patio area with a table and chairs. A locked storage space was observed on the side of the house. Incontinent care items and a wheelchair was observed. There’s a locked storage shed with a tools. Items no longer being used like bed frames, and an old sink was observed. Administrator was advised to removed the items and email LPA a photo of the backyard. A technical advisory will be issued.
Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguisher was observed mounted in the kitchen and in the garage.

An emergency drill: An emergency earthquake drill was conducted November 18, 2025. Disaster drills are conducted quarterly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:

Facility postings are posted are available for review on the main postings board at the entrance of the facility.



Additional Comments: Licensing fees are current. Facility contact information was reviewed and updated during the visit.

Deficiencies observed during the inspection will be cited.
An exit interview conducted, and a copy of the report and appeal rights were provided
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2026 01:08 PM - It Cannot Be Edited


Created By: Jerome Haley On 01/23/2026 at 12:27 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: MOMS AND DADS
FACILITY NUMBER: 306004379

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 in 2 out of 3 resident medications were pre poured in a pill container form more than 24 hours worth of medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/24/2026
Plan of Correction
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Administrator Yap agrees to review the regulation requirement with her med staff and send a signed statement of acknowledgement and understanding. AD Yap agrees to only pre pour 1-days work of meds in the residents pill container.
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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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