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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006057
Report Date: 10/28/2025
Date Signed: 10/28/2025 06:55:28 PM

Document Has Been Signed on 10/28/2025 06:55 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:SOLIVEN CARE HOMEFACILITY NUMBER:
306006057
ADMINISTRATOR/
DIRECTOR:		SOLIVEN, JOSELOLITOFACILITY TYPE:
740
ADDRESS:6710 SEQUOIA DR.TELEPHONE:
(714) 310-9293
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Joselolito SolivenTIME VISIT/
INSPECTION COMPLETED:
12:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


The facility is a single level structure and licensed for six non-ambulatory residents, of which one may be bedridden. As of today, the facility has five residents admitted to the facility. All of the residents were present during at the beginning of the visit, before one left for day program. There’s a total of 5 bedrooms (3 resident & 2 Staff) and 2 bathroom (1 resident & 1 staff) areas for residents. There’s a living room space, a dining space, backyard and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water was measured at 106.8 degrees F. Kitchen: 4 of 4 burners are operational on the gas stove. Sharps are kept locked under the sink. Cleaning chemicals are stored in a locked cabinet above the washer. A dryer is located in the kitchen across from the washer. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

Client & Staff Files: Resident and staff files are stored in the locked closet near the entrance of the facility.
File Review: 4 of 5 resident files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in the locked medication closet. A first aid kit was also observed.


Medication Review: 3 of 5 resident medications were reviewed during the visit.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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 5
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: SOLIVEN CARE HOME
FACILITY NUMBER: 306006057
VISIT DATE: 10/28/2025
NARRATIVE
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Linens & Hygiene Supplies: Hygiene items were observed in the bathroom areas in a locked cabinet space.

Garage Area: The garage is used as a storage area. Miscellaneous facility items were observed, like bed frames, mattresses, wheelchairs, walkers, and a bike. Staff items are stored in locked storage areas along the outer edges of the garage. The Licensee/ was advised to keep walkways clear and free of clutter. Licensee understood and showed LPA recently bout shelves that will be assembled in the garage to help keep it organized.
Backyard/Exterior: The backyard has a shaded patio area with a table and chairs. There were furniture items no longer being used under the patio area that need to be removed. Photos were taken. Other deficiencies were observed and photographed. See LIC9099D dated (10.28.25). LPA discussed other backyard housekeeping needs, that will assist in preventing future violations. The licensee/Administrator understood.
Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguisher was observed mounted in the kitchen.

An emergency evacuation drill: Evacuation drills was conducted July 19, 2025. Drills are conducted quarterly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:

Facility postings are posted are available for review on the main postings board at the entrance of the facility.



Additional Comments: Licensing fees are current. During the visit, 3 of 5 resident files were reviewed, 3 of 5 resident medications were reviewed and 3 staff files were reviewed during the visit. Facility contact information was updated during the visit.

Deficiencies observed during the inspection will be cited.
An exit interview conducted, and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/28/2025 06:55 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/28/2025 at 01:35 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: SOLIVEN CARE HOME
FACILITY NUMBER: 306006057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview confirmation, the licensee did not comply with the section cited above, as Resident 1 (R1) unsecured medication was observed in a pill container sitting on a night stand in the residents room which poses an immediate health and safety risk to persons in care. Medications were removed immediately.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee agrees to conduct an in-service training on medications administration and medication storage. Licensee Soliven will email LPA Haley a sign in sheet for all staff in attendance of the medication training, as well as an outline of the topics covered and the duration of the in-service training. POC will be emailed to LPA Haley by 4:00pm on the POC due date.
Type A
Section Cited
CCR
87303(f)

Maintenance and Operation
(f) All waste shall be located, stored and disposed of in a manner that will not transmit communicable diseases or odord, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.
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 as fallen fruit and dog feces was observed on the ground in the backyard. The fallen fruit was in various stages of decomposition and the dog feces was left behind was also mixed in variety, with some of the feces fresher than other feces that was observed, which poses an immediate health, safety and personal rights risk to persons in care. Photos were taken.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee Soliven agrees to clean the backyard and remove all the fallen fruit and dog feces and email LPA Haley a photo of the clean backyard. Licensee will also include a schedule of the ongoing cleaning that will be conducted in the backyard with a list of who will be responsible for the cleaning on the scheduled cleaning days. POC will be emailed to LPA Haley by 4:00pm on the 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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 06:55 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/28/2025 at 04:14 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: SOLIVEN CARE HOME
FACILITY NUMBER: 306006057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)

Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview confirmation, the licensee did not comply with the section cited above, as 2 of 5 residents had a physicians report older than one year old which poses a potential health and safety risk to residents in care.
POC Due Date: 10/31/2025
Plan of Correction
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Licensee Soliven will schedule a routine visit for the two residents by the poc due date and email LPA Haley the scheduled appointment information. Once the visits are completed, the updated physicians report will be emailed to LPA Haley.
Type B
Section Cited
CCR
87303
Maintenance and Operation
(2) The facility shall be clean, safe, sanitary, and in good repair at all times... 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 as old furniture items no longer being used were observed in the backyard under the shaded patio area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2025
Plan of Correction
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Licensee Soliven will have all the items removed from the backyard and a photo will be emailed to LPA Haley once completed. The correction is due by 4:00pm on the 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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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