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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006091
Report Date: 04/16/2026
Date Signed: 04/16/2026 04:26:34 PM

Document Has Been Signed on 04/16/2026 04:26 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:PRISTINE HOME CAREFACILITY NUMBER:
306006091
ADMINISTRATOR/
DIRECTOR:		ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:9252 PACIFIC AVETELEPHONE:
(657) 214-2845
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
04/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Oswaldo "Israel" Lara Bautista, Administrative DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 1pm. LPA briefly met with Administrator (AD) Mary Jean Alvarado who had a conflicting appointment. LPA conducted the visit with the Administrative Designee (AD) Oswaldo "Israel" Bautista.

The facility is a six bedroom, three bathroom single-residence home with a fire clearance of six non-ambulatory residents; of which six may be on hospice. Currently there are five residents in care.

During today's visit, LPA toured the dining room and living room. One resident was observed speaking on the phone, four residents were reclining in their bedrooms after eating lunch. The refrigerator had a two-days of perishable food and the facility retained seven-days of non-perishable food on-hand. Kitchen appliances were operational. Sharps and knives were secured in a locked drawer and cleaning and chemical supplies were secured beneath the kitchen sink.

Smoke alarms and carbon monoxide detectors were inspected. Both fire and carbon monoxide alarms were operational. Two fire extinguishers were charged and serviced on November 17, 2025 and the facility conducted their last fire drill on January 20, 2026. LPA inspected hot water temperatures in two of two resident bathrooms. The hot water temperature ranged between 116.0 to 116.9 degrees Fahrenheit. The facility temperature was a comfortable seventy-three degrees. All resident bedrooms were clean, beds had linens and all rooms had the required furnishings.

(Continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2026
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: PRISTINE HOME CARE
FACILITY NUMBER: 306006091
VISIT DATE: 04/16/2026
NARRATIVE
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(Continued from LIC 809)

LPA toured the exterior of the property and observed a large shaded seating area for residents and ample space for residents to walk in the backyard. The facility had self-latching gates. LPA toured the garage and observed a working washer and dryer, emergency supplies and an additional refrigerator and freezer. A workout area was also observed.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. Four of four staff who provide direct care to the residents have expired First Aid/ Cardiopulmonary certificates. A Type A deficiency will be given. Two of three staff records did not have twenty hours of staff training. Additionally, two of five resident records did not have completed Appraisal Needs and Services Plans. Type B deficiencies were cited.

LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on June 8, 2028. A copy of the Legionnaire's Disease Fact Sheet was also provided to the facility for Assisted Living Facility Administrators.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Oswaldo "Israel" Bautista, Administrative Designee and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/16/2026 04:26 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 04/16/2026 at 03:46 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: PRISTINE HOME CARE
FACILITY NUMBER: 306006091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and interview, the licensee did not comply with the section cited above in two out of three employee files which poses an immediate health, and safety risk to five of five residents in care.
POC Due Date: 04/17/2026
Plan of Correction
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At lease one staff membershall obtain First Aid/ CPR recertification by POC due date. First Aid/ CPR certificates are to be emailed to LPA.
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2026 04:26 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 04/16/2026 at 03:46 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: PRISTINE HOME CARE
FACILITY NUMBER: 306006091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and interviews, the licensee did not comply with the section cited above in two of three employee files reviewed which poses a potential health, safety and personal rights risk to five of five residents in care.
POC Due Date: 05/15/2026
Plan of Correction
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Administrator Designee stated all staff will have twenty hours of required trarining by POC due date. Documention will be emailed to LPA.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review and interviews, the licensee did not comply with the section cited above in two of five resident files which poses a potential health and safety risk to all residents in care.
POC Due Date: 05/15/2026
Plan of Correction
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Administrator Designee will complete Appraisal Needs and Services Plans by POC due date and email LPA documentation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
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