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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004559
Report Date: 09/15/2025
Date Signed: 09/15/2025 04:00:29 PM

Document Has Been Signed on 09/15/2025 04:00 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN HEARTS ELDERLY CAREFACILITY NUMBER:
306004559
ADMINISTRATOR/
DIRECTOR:		NARGIS ELAHIFACILITY TYPE:
740
ADDRESS:27778 BAHAMONDETELEPHONE:
(949) 716-0016
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 6DATE:
09/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Nargis ElahiTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Golden Hearts Elderly Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 1 resident on hospice. Administrator Nargis Elahi has an administrator certificate valid until 11/11/2026.
LPA Lyman along with Administrator Elahi toured the facility at 10:29 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean and sanitary. The home consists of six resident bedrooms, 3 common restrooms, 1 resident restroom, one staff room, living room, dining room, and kitchen. Facility has a second story where the licensee resides. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 10:35 AM, LPA observed rooms for Residents #3 and #5 do not match the facility floor plan. The room has been split making two rooms where there is one on the floor plan. LPA observed two residents with full rails and one resident with half rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 94.2 degrees F and 101 degrees F in all facility restrooms. Resident bath towels and toiletries were adequately stocked at time of visit. Common areas were clean and clear of hazards. First aid kit had all the elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 10:50 AM, LPA observed unsecured knives and scissors in an unlocked cabinet. Smoke detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. CONT ON LIC809-C DATED 09/15/2025
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559
VISIT DATE: 09/15/2025
NARRATIVE
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LPA reviewed the emergency disaster plan and infection control plan during the visit. Facility does not have proof of quarterly emergency drills. Facility provides activities in the form of exercise and puzzles. At 11:15 AM, LPA reviewed six resident files and one staff file. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Three out of six residents do not have updated appraisals/ physician reports. Resident 1 has full rails and is not on hospice care. One out of one resident does not have a physician order for bed rails. Staff file reviewed contained required documentation as well as CPR training and criminal record clearance. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Facility does not have orders for supplements/ PRN medications nor is documenting PRN usage. Facility does not use a medication administration record.




Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator and a copy was provided as well as appeal rights
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/15/2025 04:00 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/15/2025 at 01:55 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: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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. LPA observed knives and scissors unsecured in a kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility does not have documentation of quarterly emergency drills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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Licensee to conduct drill and forward proof to LPA by POC due 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 04:00 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/15/2025 at 01:55 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: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. Facility does not have a carbon monoxide detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to obtain and install a carbon monoxide detector and forward proof to LPA by POC due date. Licensee installed carbon monoxide during the visit.
Type B
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 three out of three faucets with temperature ranging from 94-101 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to adjust water temperature and forward proof to LPA by POC due 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 09/15/2025 04:00 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/15/2025 at 01:55 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: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review the licensee did not comply with the section cited above in one out of one staff without required annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to obtain training for staff including 4 hours of postural support, restricted conditions and hospice and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of six residents with PRN medications not being documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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License to maintain documentation for PRN administration and forward proof to LPA by POC due 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 04:00 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/15/2025 at 01:55 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: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three out of six residents (R 1, 3, and 6) without updated appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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2
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Licensee to obtain updated appraisals/ physician reports and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in one out of six residents (R6) without physician orders for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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2
3
4
Licensee to obtain order for bed rail and forward proof to LPA by POC due 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 04:00 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 09/15/2025 at 02:19 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: GOLDEN HEARTS ELDERLY CARE
FACILITY NUMBER: 306004559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, Two resident rooms do not match the floor plan in which the licensee put up a wall splitting the room in half which negates fire clearance granted to the facility which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED
POC Due Date: 09/16/2025
Plan of Correction
1
2
3
4
Licensee to submit an LIC 200 and updated floor plan to LPA by POC due date.
Type A
Section Cited
CCR
87608(a)(5)(b)
Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one out of one resident with full rails and not on hospice which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
1
2
3
4
Licensee to remove rails and forward proof to LPA by POC due 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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