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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004478
Report Date: 02/11/2026
Date Signed: 02/11/2026 12:48:44 PM

Document Has Been Signed on 02/11/2026 12:48 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:PRINCEVILLE - COLLEGE PARKFACILITY NUMBER:
306004478
ADMINISTRATOR/
DIRECTOR:		MYRIAM OLIVERFACILITY TYPE:
740
ADDRESS:3601 OLEANDER STREETTELEPHONE:
(562) 296-8800
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY: 6CENSUS: 5DATE:
02/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Myriam Oliver and Karl Padua, AdministratorsTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On February 11, 2026, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley introduced self and was granted entry into the facility, after stating the purpose of the visit to Administrator Myriam Oliver. Administrator Karl Padua arrived shortly to assist with the visit.

The facility is licensed to operate for six (6) non-ambulatory, with a Hospice waiver for four. The building is a one-story home located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, two and one-half bathrooms, living room area, kitchen, outdoor covered seating area, and an attached two car garage.

During the visit, LPA toured the inside and outside of the physical plant with AD Olivier. There were no bodies of water or obstructions on the premises. All rooms were inspected, beds and bedding supplies were in good condition, and storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature of 76 degrees F was maintained throughout the facility. Bathrooms were found to be clean and operational, with water temperatures in bathrooms measured between 112 degrees F and 116 degrees F.

The smoke alarms and carbon monoxide detectors were operable. First aid kit is maintained and contains all the necessary elements. Emergency safety drills were last conducted on December 18, 2025. The facility has one (1) fire extinguisher that was charged and purchased on February 11, 2026.

CONTINUE LIC809-C.....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2026
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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Document Has Been Signed on 02/11/2026 12:48 PM - It Cannot Be Edited


Created By: Eboni Bentley On 02/11/2026 at 11:58 AM
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: PRINCEVILLE - COLLEGE PARK
FACILITY NUMBER: 306004478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in four out five resident medication records, which poses an immediate risk to persons in care. LPA observed the facility did not have updated centrally stored medication records for four out of five residents and MARs for five out of five residents in care for the month of February 2026.
POC Due Date: 02/12/2026
Plan of Correction
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Administrator to forward proof of the most current/active centrally stored medication records and MARs for R1-R6 to LPA by POC due date. Administrator stated that he will provide medication training to all staff regarding pre-pouring of medicaitons and will provide proof of training to LPA by POC due date. Administrator will dispose of all discontinued medication in the by 2/12/2026.
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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2026 12:48 PM - It Cannot Be Edited


Created By: Eboni Bentley On 02/11/2026 at 12:07 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: PRINCEVILLE - COLLEGE PARK
FACILITY NUMBER: 306004478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in three out of the five resident bedrooms by placing a camera in the bedroom, which poses a personal rights risk to persons in care. Camera were removed during the visit.
POC Due Date: 02/18/2026
Plan of Correction
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Administrator stated that they will either submit an exception or no longer utilize the camera moving forward and to submit an Acknowledegment of Understanding for the said deficiency to LPA via email by POC due date.
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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


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: PRINCEVILLE - COLLEGE PARK
FACILITY NUMBER: 306004478
VISIT DATE: 02/11/2026
NARRATIVE
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Current Liability Insurance was provided during the visit with a policy start date of March 11, 2025 through March 11, 2026. A working telephone (562)296-8800 remains available and the facility has a device that can be used for video teleconference purposes.
LPA conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S3), and medication and medication administration record review. Resident and staff interviews were conducted. Based on today’s observations and record review, 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 with Administrators Myriam Oliver and Karl Padua, and a copy of this report, LIC809-D, and appeals right were provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC809 (FAS) - (06/04)
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