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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005977
Report Date: 03/19/2026
Date Signed: 03/19/2026 12:38:27 PM

Document Has Been Signed on 03/19/2026 12:38 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:FOUNTAIN VIEW CARE HOMEFACILITY NUMBER:
306005977
ADMINISTRATOR/
DIRECTOR:		ORTIZ-LUIS, VIVIAN ANNFACILITY TYPE:
740
ADDRESS:17688 SAN FRANCISCO STTELEPHONE:
(626) 272-5906
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 4DATE:
03/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Vivian Ann Ortiz- Luis - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On March 19, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purposes of conducting a required 1-Year annual visit using the CARE Inspection Tool. LPA Bentley was greeted and granted entry by staff, after stating the reason for the visit. Administrator (AD) Vivian Ann Ortiz- Luis was contacted by telephone and permission was granted for Caregiver to sign today’s inspection report.

The facility is licensed to operate for age range 60 and over and approved for (6) non-ambulatory, of which one (1) may be bedridden in Room #3 only, with a Hospice waiver for six (6). The building is a single story structure located in a residential neighborhood, which consists of the following: six (6) resident bedrooms, one (1) staff bedrooms, two (2) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

LPA Bentley toured inside and outside of the physical plant with staff. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked and available at the time of visit. Bathrooms were found to be clean and operational. The water temperatures in bathrooms measured at 112.8 degrees F to 113.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.


CONTINUE TO LIC-809-C.....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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 03/19/2026 12:38 PM - It Cannot Be Edited


Created By: Eboni Bentley On 03/19/2026 at 12:03 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: FOUNTAIN VIEW CARE HOME
FACILITY NUMBER: 306005977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(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 section cited above in four out of four stove burners, which poses a potential health and safety risk to persons in care. LPA observed four out of four non-operational stove burners that are in need of repair. LPA also observed four cabinet doors in need of repair with two hanging off the henges and two unable to close.
POC Due Date: 03/26/2026
Plan of Correction
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Administrator stated the stove will be replaced and cabinet doors will be repaired by POC due date. Administrator will submit proof to CCLD and LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


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: FOUNTAIN VIEW CARE HOME
FACILITY NUMBER: 306005977
VISIT DATE: 03/19/2026
NARRATIVE
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LPA Bentley observed the facility to be appropriately furnished at the time of visit. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available. LPA observed four non-operational stove burners that do not self ignite and four cabinet doors in need of repair, with two hanging off the hinges and two unable to close. A deficiency is being cited.

The smoke alarms and carbon monoxide detectors were operable. An emergency safety drill was last conducted on January 20, 2025, and are conducted quarterly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted, and serviced on January 5, 2026. First aid kit is maintained and contains all the necessary elements. A working telephone (714-963-0026) remains available, however the facility does not have a device that can be used for video teleconference purposes. A Technical Violation was provided.

LPA Bentley conducted an audit of four (4) resident files (R1-R4), three (3) staff files (S1-S3), and medication and medication administration review were all in order and complete. LPA Bentley conducted four (4) resident interviews and two (2) staff interviews. Liability Insurance is effective August 8, 2025, and expires on August 8, 2026.

Based on today’s observations, a deficiency is being cited during the visit, per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted with staff, and a copy of this report, LIC809-D, and Appeal Rights was provided 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: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC809 (FAS) - (06/04)
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