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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005352
Report Date: 10/10/2025
Date Signed: 10/10/2025 04:09:49 PM

Document Has Been Signed on 10/10/2025 04:09 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:DIGNITY & WISDOMFACILITY NUMBER:
306005352
ADMINISTRATOR/
DIRECTOR:		TESFAY, SABAFACILITY TYPE:
740
ADDRESS:17331 VINEWOOD AVENUETELEPHONE:
(714) 368-9058
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
10/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Saba Tesfay - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry by staff and explained the reason for the visit.

The facility is a single story home with four bedrooms, two and a half bathrooms, a sun room and a detached garage with an approved fire clearance of six non-ambulatory residents, of which one may be bedridden, and an approved hospice waiver for three. The facility currently has a census of five residents in care and one resident on hospice.

During today’s visit, LPA and Administrator Saba Tesfay toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in 3 out of 3 bathrooms and kitchen sink. The hot water temperature measured 97.3, 104.3 and 106.8 degrees Fahrenheit in bathrooms and 102.2 degrees Fahrenheit in the kitchen and all smoke detectors were operational. Facility does not have documentation emergency drills are conducted quarterly for 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand.LPA observed emergency food and water in the garage and pantry. LPA observed cobwebs in the following areas, hallway cabinet where linens are stored, laundry area in behind washer/dryer and in kitchen cabinet on left hand of stove. LPA did not observe an oxygen sign for a resident that is using an oxygen tank. LPA observed unsecured insulin injections in facility fridge, staff stated residents do not self administer injections. LPA observed Resident 1 (R1) in a non-ambulatory room when they are listed as bedridden per physician's report.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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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Document Has Been Signed on 10/10/2025 04:09 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 10/10/2025 at 11:41 AM
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: DIGNITY & WISDOM
FACILITY NUMBER: 306005352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation licensee did not comply with the cited above as there is not a "No Smoking- Oxygen In use" posted in facility with a resident that is utilizing oxygen. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/11/2025
Plan of Correction
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Administrator corrected during visit.
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed the licensee did not comply with the following in 2 out of 2 resident that receive insulin as they are not self administering injections and are not getting injections by a skilled professional. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/11/2025
Plan of Correction
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Administrator stated will administer insulin to both residents as she is a Nurse Practioner (licensed viewed by LPA. Administrator stated will contact R1's physician for updated orders for insulin to orally. Administrator stated will submit an exception for Resident 2 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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DIGNITY & WISDOM
FACILITY NUMBER: 306005352
VISIT DATE: 10/10/2025
NARRATIVE
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LPA reviewed two of two staff training and fingerprint records and conducted a complete review of five out of five resident records. LPA confirmed that administrator Saba has a current administrator certificate which expires on May 30th, 2027.

LPA Mendivil consulted with Administrator Saba regarding reporting requirements and the importance of documentation.

Based on observations made deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/10/2025 04:09 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 10/10/2025 at 12:00 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: DIGNITY & WISDOM
FACILITY NUMBER: 306005352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
(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 obseveration and record review the licensee did not comply with the regulation above as Resident 1 (R1) resides in a room that is not cleared for bedridden resident. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Administrator stated will get updated physicians report for R1 to state non-ambulatory as Administrator stated R1 is not bedridden. Licensee agreed if physicians report is not udpdated will move R1 from bedroom 2 to bedroom 3.
Type A
Section Cited
CCR
87303(e)(2)
(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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in 3 out of 4 sinks as temperature read 97.3, 102.2, and 104.3 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/11/2025
Plan of Correction
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Administrator agreed to adjust water heater and provide proof to LPA that water temperatures are within range. Administrator agreed to conduct quarterly water temperature checks and retain document for review.
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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 04:09 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 10/10/2025 at 12:10 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: DIGNITY & WISDOM
FACILITY NUMBER: 306005352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) 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 regulation cited above as the facility has cobwebs in multple locations including: hallway cabinet where linens are stored, laundry area in behind washer/dryer and in kitchen cabinent on left hand of stove. LPA also observed screens in bathroom #2 and #3 to be in disrepair.This poses a potential health and safety risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee to clean faciltiy and replace screens in bathrooms and provide proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695
(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 observation and records reviewed the licensee did not comply with the cited above as there is no record of emergency drills conducted in 2025. This poses a pontential health and safety risks to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Administrator agreed to conduct emergency drills and provide 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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 04:09 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 10/10/2025 at 12:19 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: DIGNITY & WISDOM
FACILITY NUMBER: 306005352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


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 cited above as LPA Mendivil observed unsecured medications in refrigerator. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/11/2025
Plan of Correction
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Administrator corrected during visit.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2025


LIC809 (FAS) - (06/04)
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