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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005760
Report Date: 05/05/2025
Date Signed: 05/05/2025 03:50:18 PM

Document Has Been Signed on 05/05/2025 03:50 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:ARABELLA CARE VILLAFACILITY NUMBER:
306005760
ADMINISTRATOR/
DIRECTOR:		NORA, MARY JOYCEFACILITY TYPE:
740
ADDRESS:1923 WEST CHATEAU AVETELEPHONE:
(714) 251-4302
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 3DATE:
05/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Mary Joyce NoraTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Mary Joyce Nora and explained the reason for the inspection. There are currently three residents at the facility of which all were seen watching tv and napping.

The facility is a one story home with three resident bedrooms, one resident bathroom, one staff bedroom, one staff bathroom, kitchen, living room, dining room, laundry room, attached two car garage and backyard. Facility appears clean, safe and sanitary. LPA observed the kitchen to be free of debris and vermin. LPA observed the toxins to be stored under the locked kitchen sink and made inaccessible to residents in care. LPA observed the sharps to be in a locked kitchen cabinet located next to the fridge and made inaccessible to residents in care. LPA observed the stove burners to be in working condition and have locks on them making it inaccessible to residents. LPA observed a fire extinguisher located by the kitchen to be charged with a service date of October 2, 2024. LPA observed the laundry room toxins to be locked in a cabinet located above the washer. LPA observed the emergency food and water supply to be located in the locked garage. LPA observed that all resident bedrooms had the required components and furnishings. LPA observed the resident bathroom to have toilet paper, paper towels and non slip floor mats. LPA observed the water temperature to be measured at 110 degrees Fahrenheit located in the residents bathroom in the hallway. LPA observed extra clean linens for residents use stored in the hall cabinet. LPA observed the staff bedroom to be locked and made inaccessible to residents in care. LPA observed all doors to have alarmed exits. LPA observed the backyard to be free of obstructions. LPA observed the backyard to have a shaded seating area for resident use. LPA observed the activities calendar along with extra activities in the facility such as books, puzzles and musical items. Continue on 809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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: ARABELLA CARE VILLA
FACILITY NUMBER: 306005760
VISIT DATE: 05/05/2025
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LPA reviewed resident and staff files, no discrepancies were observed. LPA reviewed resident medication and no discrepancies were observed. LPA tested the carbon monoxide and fire detectors and they were found to be operational. LPA observed that the last fire drill was conducted on April 4, 2025. All staff present have been background cleared and are associated to the facility.

Based on today’s inspection no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Mary Joyce Nora and a copy of this report was given at the time of inspection.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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