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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005599
Report Date: 05/14/2025
Date Signed: 05/14/2025 04:09:11 PM

Document Has Been Signed on 05/14/2025 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A1 ELDER CAREFACILITY NUMBER:
306005599
ADMINISTRATOR/
DIRECTOR:		SHAH, BINDIFACILITY TYPE:
740
ADDRESS:2538 E LARKSTONE DRIVE #ATELEPHONE:
(949) 929-5318
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
05/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Bindi ShahTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On May 14, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of conducting 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) Bindi Shah was notified via telephone and later arrived to assist with the inspection. LPA observed that Bindi Shah has a valid administrator certificate which expires on June 27, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for four. The facility is a two story home with five resident bedrooms, one of which is shared, three resident bathrooms, a living rooms, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care, two of which are on hospice, and two care giving staff present. LPA observed residents relaxing in their respective bedrooms and in the living room. LPA inspected the five resident bedrooms and they were observed to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms were clean. Resident bathrooms were equipped with grab bars and non-skid floors. Faucets and toilets were operational. Hot water temperature measured between 117.5 and 119.7 degrees Fahrenheit. The second story of the home if for staff use only and is off limits to residents in care.

LPA observed the kitchen has a two day perishable and a seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
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: A1 ELDER CARE
FACILITY NUMBER: 306005599
VISIT DATE: 05/14/2025
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LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a separate locked kitchen cabinet. LPA observed a fire extinguisher to be mounted in the kitchen and it was observed to be charged and serviced as of May 12, 2025. LPA tested the wired smoke detectors which tested operational. LPA tested the individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on April, 2025.

LPA observed the centrally stored medication to be kept in a locked hallway closet. LPA observed the facility has a First Aid Kit stored in the locked closet and it had all the required components. LPA observed the facility has a three day emergency food and water supply stored in a hallway closet. LPA observed fireplaces in the living room and by the resident hallway and they were observed to be adequately fenced and not in operation at time of visit. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage and laundry.

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. LPA observed the perimeter gates on the west side and east side of the facility to be self latching and can be opened in an evacuation. There is a pool located in the backyard which was observed to be adequately fenced and kept locked for resident safety.

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

Based on the observations made during today's visit, one deficiency is being cited on the attached 809-D. An exit interview was conducted with Administrator Bindi Shah. A copy of the report and Appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2025 04:09 PM - It Cannot Be Edited


Created By: Brandon Lopez On 05/14/2025 at 03:51 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: A1 ELDER CARE
FACILITY NUMBER: 306005599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the facility does not have a See Something, Say Something poster (PUB 475) in the facility.
POC Due Date: 05/30/2025
Plan of Correction
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AD agreed to purchase the PUB 475 poster and mount it on the wall by the entryway of the facility. AD agreed to provide proof of purchase to LPA and to send a picture of the poster once it has been mounted on the wall. AD agreed to provide proof of purchase and the picture of the poster to LPA via email or fax by POC 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
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