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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005309
Report Date: 09/23/2025
Date Signed: 09/23/2025 12:03:04 PM

Document Has Been Signed on 09/23/2025 12:03 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:QUEEN'S HOME IFACILITY NUMBER:
306005309
ADMINISTRATOR/
DIRECTOR:		MAGHBOULEH, KATAYOUNFACILITY TYPE:
740
ADDRESS:24422 ZANDRA DRIVETELEPHONE:
(949) 716-1835
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
09/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Kathy Maghbouleh- Administrator
Arya Maghbouleh- Administrator
Arash Maghbouleh- Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Ronelex Dalut and stated the reason for the visit. Administrator (Admin) Arya Maghbouleh arrived on premise and remained at the facility to assist with the inspection. Admin Arya has a valid administrator's certificate expiring on August 17, 2027, August 17, 2027 for Arash Maghbouleh, and August 15, 2027 for Arlene Mahinay

The following was observed during the inspection:
This is a single story property located in a residential neighborhood comprised of five resident bedrooms and two resident bathrooms. Facility operates within the conditions and limitations specified on the license. LPA observed four residents in care of which two are receiving hospice services. LPA observed three caregivers on duty and verified fingerprint clearance and association statuses including the administrators. LPA toured the interior portion of the facility. All common areas were inspected which includes the laundry room and attached two car garage. The fireplace was screened. LPA inspected the five resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be in compliance, clean, and operational. The hot water temperature in both bathrooms measured at 112.8 and 111.3 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The two exit gates on each side of the property were operational, and there were sufficient seating and shading in the patio area.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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: QUEEN'S HOME I
FACILITY NUMBER: 306005309
VISIT DATE: 09/23/2025
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The two fire extinguishers were serviced on June 13, 2025 per review of the invoice. The auditory devices and smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency food/water and supplies in the closet and kitchen. The first aid kit had all necessary elements. Fire drills were conducted monthly. The required Complaint Poster (PUB475) poster was posted in the entry way in the correct size requirement.

LPA reviewed four out of four resident files and three personnel files in which no discrepancies were found. Facility maintained all bed rail orders for the three residents. Medications were audited for two out of four residents and no discrepancies were found.

The following was addressed during the visit: to ensure the emergency drills conducted account different emergency scenarios. Admins were advised to inform the Department prior to making any alterations and will provide a plan as discussed during the consult.

Based on the observations made during today's visit, no deficiencies are being cited. An Advisory Note is being issued.

An exit interview was conducted with Administrators Kathy Maghbouleh, Arya Maghbouleh, and Arash Maghbouleh, and a copy of this report was provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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