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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004510
Report Date: 01/12/2026
Date Signed: 01/12/2026 03:59:01 PM

Document Has Been Signed on 01/12/2026 03:59 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:LOVING CARE SENIOR HOMEFACILITY NUMBER:
306004510
ADMINISTRATOR/
DIRECTOR:		MAI T. NGUYENFACILITY TYPE:
740
ADDRESS:9435 KIWI CIRCLETELEPHONE:
(714) 867-8074
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Tuyet Nguyen - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On January 12, 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 by staff, after stating the purpose of the visit. Licensee (LI) Mai Nguyen was contacted via telephone and granted permission of Caregiver Tuyet Nguyen to sign the facility report in her absence.

The facility is licensed to operate for six (6) non-ambulatory residents, with a Hospice waiver for two (2) residents. The building is a single-story home located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, two (2) bathrooms, living room area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

During the visit, LPA toured inside and outside of the physical plant with staff and spoke with LI via telephone. 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 resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature of 70 degrees F was maintained in the facility. Bathrooms were found to be clean and operational; however, the water temperature in two resident bathrooms measured between 131.2 degrees F and 139.1 degrees F. The kitchen was inspected and LPA observed four non-operational range burners on the stove, used for preparing meals for residents in care. Deficiencies were being cited.

Continues on LIC 809-C ...

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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 6
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 01/12/2026 03:59 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/12/2026 at 03:15 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: LOVING CARE SENIOR HOME
FACILITY NUMBER: 306004510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 two out of two bathroom faucets, which poses an immediate healthy and safety risk to persons in care. LPA observed water temperatures between 131.2 and 139.1 degrees F in bathrooms used by residents in care.
POC Due Date: 01/13/2026
Plan of Correction
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Licensee stated they will test water temparures in two bathrooms over the next 24 hours and submit water temperature logs to CCLD by POC due date via eboni.bentley@dss.ca.gov
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section above in one out of five bedrooms used by residents in care. LPA observed a medical assessment indicating Resident #1 (R1) has an ambulatory status of Bedridden and living in Bedroom #1, which is a non-ambulatory room. The facility does not have a Fire Clearance for Bedridden bedrooms and is not licensed to care for Bedridden residents.
POC Due Date: 01/13/2026
Plan of Correction
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Licensee stated plan to submit LIC 200 application and 850 form immediately requesting new fire clearance for Bedridden room at current facility by POC due date. Licensee stated they plan to transfer Bedridden resident to another licensed facility within 24 hours where a Bedridden room is available and submit proof to CCLD by 5pm on POC due date via eboni.bentley@dss.ca.gov
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: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


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: LOVING CARE SENIOR HOME
FACILITY NUMBER: 306004510
VISIT DATE: 01/12/2026
NARRATIVE
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The smoke detectors and carbon monoxide detectors were operable. First aid kit is maintained and contains all the necessary elements. Emergency safety drills were last conducted on October 12, 2025. The facility has one (1) fire extinguisher that was charged and purchased on January 12, 2026. Current Liability Insurance was provided during the visit with a policy start date of June 17, 2025, through June 17, 2026. A working telephone (714)274-9802 remains available.

No emergency food, emergency water, or emergency supplies were observed. A deficiency was cited. The facility does not currently have a device that can be used for video teleconference purposes. LPA provided Technical Assistance.

LPA conducted an audit of five (5) resident files (R1-R5), three (3) staff files (S1-S), and medication and medication administration review. Resident and staff interviews were conducted. Based on record review, the facility currently has one bedridden Resident #1 (R1) with a fire clearance for six (6) non-ambulatory only residents. A deficiency was 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, LIC809-D, Technical Assistance, and appeal rights were provided to staff at exit.

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

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/12/2026 03:59 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/12/2026 at 03:28 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: LOVING CARE SENIOR HOME
FACILITY NUMBER: 306004510

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303
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 in four out of four stove burners, which poses a potential healthy and safety risk to persons in care. LPA observed four non-operational range burners on the stove, used for preparing meals for residents in care.
POC Due Date: 01/20/2026
Plan of Correction
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Licensee stated they will repair all four burners on the stove top or purchase new operational stove and provide proof to CCLD by POC due date via eboni.bentley@dss.ca.gov
Type B
Section Cited
HSC
1569.695(a)(2)
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interview, the licensee did not comply with the section cited about, which poses a potential risk to residents in care. LPA did not observe any emergency water and food supply. Licensee stated they will buy additional cases of water and canned goods for emergency use only.
POC Due Date: 01/20/2026
Plan of Correction
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Licensee stated purchase sufficient amount of emergency water and food supply for residents and staff and submit proof to CCLD by POC due date via eboni.bentley@dss.ca.gov
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: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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