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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 08/29/2025
Date Signed: 08/29/2025 04:51:08 PM

Document Has Been Signed on 08/29/2025 04:51 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:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR/
DIRECTOR:		JAE WAN RIMFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 197CENSUS: 152DATE:
08/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Jae Wan RimTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On August 29, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted LPA on today's inspection. LPA observed that Jae Wan Rim has a valid Administrator certificate which expires on May 15, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and ninety seven residents and has a hospice waiver for twenty five. The facility is a two story building. The first floor consist of a lobby, five staff offices, an activity room, a lounge, a laundry room, a commercial kitchen, a dining room, a maintenance room, resident bedrooms, with bathrooms located in suite, and an outdoor courtyard area. The second story consist of a lounge, a dining room, resident bedrooms, with bathrooms located in suite, and a outdoor patio area. On today's visit, there are one hundred and fifty two resident in care. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected ten resident bedrooms on the first and second floor and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in the laundry room. LPA additionally tested the alarm systems in the resident bedrooms which tested operational. LPA inspected the resident bathrooms in each of the resident bedrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 106.8 and 116 degrees Fahrenheit.

LPA observed the commercial kitchen to be kept off limits to residents in care. LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FULLERTON VILLA
FACILITY NUMBER: 306004839
VISIT DATE: 08/29/2025
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LPA observed kitchen appliances to be clean and operational. LPA observed knives and sharps to be stored in the kitchen. LPA observed fire extinguishers to be mounted on the walls throughout the first and second floor of the facility. LPA observed fire extinguishers to be charged and serviced as of December 19, 2024. LPA observed the facility passed their most recent fire inspection conducted on August 19, 2025. The fire inspection consisted of testing the facility smoke detectors, carbon monoxide detectors, and fire sprinklers, all of which tested operational. LPA observed the facility conducted their last emergency disaster drill on July 28, 2025.

LPA observed the centrally stored medication to be kept in a locked cabinets located in the nurse's office located on the first floor. LPA also observed the facility has a First Aid Kit stored in the nurse's office and it has all the required components. LPA observed all facility common areas such as the lounges on the first and second floor, the dining rooms of the first and second floor, the activity rooms on the first and second floor, to be clear of any obstructions or hazards. LPA inspected all facility staircases and observed them to be clear of hazards. LPA also observed each staircase to have an emergency evacuation chair. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all facility chemicals and toxins to be kept locked in the maintenance room.

LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. There are no bodies of water on the premises.

LPA reviewed fifteen resident files. All the required documentation were present and current in the resident file reviewed. LPA reviewed the residents' medication and medication records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Jae Wan Rim and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
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