306005201-12-18-2025-22-AS-RMRT-DPGQQH-20251218112221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005201
Report Date: 12/18/2025
Date Signed: 12/18/2025 11:23:02 AM

Document Has Been Signed on 12/18/2025 11:23 AM - 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-BOLSA CHICA		FACILITY NUMBER:	306005201
ADMINISTRATOR/ DIRECTOR:	OLIVER, MYRIAM		FACILITY TYPE:	740
ADDRESS:	5191 VALLECITO AVE		TELEPHONE:	(714) 622-5337
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6		CENSUS: 6	DATE:	12/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Karl Padua, Administrator (AD)		TIME VISIT/ INSPECTION COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8am. LPA met with Administrator (AD) Karl Padua and explained the purpose of the visit. The facility is a six- bedroom, two-and-a-half bathroom, single story home with a fire clearance for six non-ambulatory residents and hospice waiver approved for six residents. The facility currently has a census of six residents in care and four residents on hospice. During today's visit, LPA toured the facility and tested carbon monoxide and smoke detectors and both were operational. LPA observed a video camera in the common area that does not have audio. LPA observed the fire extinguisher was charged and inspected on November 3, 2024. The facility conducted their last fire drill on December 12, 2025. The facility was clean and there were no odors detected. LPA inspected the kitchen and all of the stove burners are in working order. Cleaning chemicals and disinfectants were secured beneath the sink and knives/sharps were secured in a drawer. The refrigerator had the required two day perishable items and the pantry had seven days of non-perishables on-hand. Fruits were observed on the counter and, at time of the entry, residents were eating breakfast. Emergency water was in the garage. While touring the interior LPA observed the PUB 475 posted, as well as Personal Rights, Resident Council information and Visiting Hours. LPA tested two of two resident bathroom water temperatures. The hot water temperatures ranged between 105.3 to 108.1 degrees Fahrenheit. Showers had grab bars and non-skid (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

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: PRINCEVILLE-BOLSA CHICA	FACILITY NUMBER: 306005201
	VISIT DATE: 12/18/2025

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(Continued from LIC 809)

mats and all disinfectants were secured. LPA toured resident rooms and noted they had the required furnishings of tables, chairs and beds. Bed rail orders were observed on file and all linens were clean and there was an ample supply of linens in hallway closet.

LPA toured the exterior of the property and observed the exterior gates were unlocked. There was ample space for residents to walk outside and the bird bath and water fountains were empty for the winter months. LPA observed a shaded seating area and there were no hazards obstructing pathways. After breakfast, LPA observed three residents doing chair exercise and listening to music.

LPA reviewed three of three staff training and fingerprint records.and conducted a complete review of resident records. LPA observed medication storage and reviewed the centrally stored medications. Per review of Medication Administration Records, medications are being given as prescribed. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on November 16, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Karl Padua, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC809 (FAS) - (06/04)

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