306005729-7-25-2025-22-AS-WVAS-DJWUYB-20250725155940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005729
Report Date: 07/25/2025
Date Signed: 07/25/2025 03:59:46 PM

Document Has Been Signed on 07/25/2025 03:59 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 AYESHA		FACILITY NUMBER:	306005729
ADMINISTRATOR/ DIRECTOR:	DEL ROSARIO, LESTER		FACILITY TYPE:	740
ADDRESS:	452 S SWIDLER PLACE		TELEPHONE:	(657) 281-2103
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY: 6		CENSUS: 5	DATE:	07/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:39 PM
MET WITH:	Lester Del Rosario Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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	On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver Randy Hernandez, and LPA explained the purpose of the visit, set up equipment, and began a tour of the facility and observed the following. This is a one storied home with six bedrooms one of which is a staff room, and five of which are resident rooms. There are two and a half bathrooms, all of which are used for residents in care and the half bath is used for staff and visitors. LPA Vanegas observed the kitchen area to be clean and sanitary. LPA Vanegas observed a microwave, refrigerator, gas stove, dishwasher, washer, and dryer. All appeared to be in good repair, and tested operational. LPA Vanegas observed bathrooms to be clean and free of any mildew or debris, LPA Vanegas observed bathrooms to have all required furnishings such as grab bars, slip resistant floor matts, and a shower chair. LPA Vanegas observed water faucets and toilets to be in good repair and tested operational. LPA Vanegas observed water temperature to be between 102.4 and 103.7 degrees. LPA Vanegas observed all resident rooms to have required furnishings such as chest drawers, clean linens in good repair; meaning no strains or tears, a bed, a reading lamp, a chair, and enough storage space to store personal belongings. Rooms are large enough to walk about freely, and no obstructions were observed blocking entry ways. CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

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: CARE AYESHA	FACILITY NUMBER: 306005729
	VISIT DATE: 07/25/2025

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LPA Vanegas observed the outside of the facility to be large enough to participate in outdoor activities upon resident request, and an outdoor shaded sitting area was observed to be available for resident use. LPA Vanegas observed no obstructions along exit routes and noted the side gates to be self latching and unlocked.

LPA Vanegas observed first-aid kit to have all required items such as adhesive tape, tweezers, scissors, bandages, first aid manual, and a thermometer. LPA Vanegas observed all fire extinguishers to be up-to-date and fully charged. LPA Vanegas observed smoke and carbon monoxide detectors to be in good repair and tested operational.

LPA Vanegas reviewed five resident files, and five staff files. All files (Resident and Staff) had all required documents and staff training was up-to-date and documented correctly. LPA Vanegas reviewed medication administration record, and per LPA Vanegas review medications are being documented correctly and administered per physicians orders.

Based on today's inspection no deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Lester Del Rosario , and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025

LIC809 (FAS) - (06/04)

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