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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005439
Report Date: 08/08/2025
Date Signed: 08/08/2025 05:11:47 PM

Document Has Been Signed on 08/08/2025 05:11 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:CARE JORDAN SENIOR HOMESFACILITY NUMBER:
306005439
ADMINISTRATOR/
DIRECTOR:		GIDEON LIMPIADOFACILITY TYPE:
740
ADDRESS:8728 CANARY AVENUETELEPHONE:
(562) 365-4155
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Gideon Limpiado - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On August 8, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a required one-year annual visit using the CARE Inspection Tool. LPA Bentley was greeted, granted entry by staff, and explained the reason for the visit. Staff called the Administrator (AD) Gideon Limpiado via telephone who arrived a short time later and was present during the inspection.

AD Limpiado has a current Administrator Certificate with an expiration date of April 22, 2026.

Care Jordan Senior Homes is a one-story house with five (5) resident bedrooms, two (2) staff bedroom and two bathrooms. The facility is licensed for six (6) non-ambulatory residents of which one (1) may be bedridden with an approved hospice waiver for three (3) residents. Currently, there are four (4) residents on census, and all were present during today’s visit. Residents were observed in the living room, in the dining room eating lunch, and resting in their bedrooms.



During the visit, LPA conducted a tour of the physical plant accompanied by staff and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the residents’ personal belongings were observed in residents’ closets. Additional bed linens, comforters, and bath towels were available. Bathrooms were operational with water temperatures measured at 106.7 and 109.5 degrees F. in bathrooms. The kitchen was clean and organized. All knives and sharp objects were locked in a cabinet near the stove. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed.

CONTINUE TO LIC809-C....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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 08/08/2025 05:11 PM - It Cannot Be Edited


Created By: Eboni Bentley On 08/08/2025 at 04:24 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: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025

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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4
Based on record review, the licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care. LPA observed three out of four personnel files missing annual staff training on postural supports, restricted health conditions, dementia, and hospice care.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee agrees to conduct training with all three out of four staff and will submit proof of correction to LPA via CCLD email to eboni.bentley@dss.ca.gov by POC due date.
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
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety and personal rights risk to persons in care. Based on record review, LPA observed that Resident #1, Resident #2, Resident #3 and Resident #4 do not have current Appraisals/Needs and Services plans.
POC Due Date: 08/18/2025
Plan of Correction
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Licensee agrees to complete updated Appraisal/Needs and Service Plans for Resident #1, Resident #2, Resident #3, and Resident #4 and will submit proof of correction to LPA CCLD email at eboni.bentley@dss.ca.gov 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439
VISIT DATE: 08/08/2025
NARRATIVE
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LPA Bentley observed a first aid kit with all the required elements. Two (2) fully charged fire extinguishers were observed mounted with a last service date of March 21, 2025. Smoke detectors were tested and operational. LPA observed records indicating the last fire and disaster drill was conducted on June 4, 2025 and administrator also conducted drill on date of inspection.

The garage walkways were clear. There were two refrigerators with an amble number of perishable items observed. The facility has a sufficient amount of water and nonperishable food supply stored in garage. The backyard was clean and free of clutter and debris. The side exit gate was clear and accessible. There is a shaded patio area with tables and seating observed. The facility has an adequate amount of emergency food and water supply.

LPA conducted an audit of four (4) resident files (R1-R4), four (4) staff/personnel files (S1-S4). A medication and medication administration record review was also conducted. Medications are stored locked in a cabinet near the living room. Medications are being administered by physician order. LPA interviewed two (2) residents regarding their quality of care and spoke with two (2) staff present regarding the care provided.



Based on the observations made during today’s visit, deficiencies are being cited as per Title 22 Division 6 of the California Code of Regulations and two Technical Advisories were provided.

An exit interview was conducted, and a copy of this report, LIC809D and appeal rights provided to Administrator Gideon Limpiado at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

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

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