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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006096
Report Date: 09/30/2025
Date Signed: 10/02/2025 12:12:37 PM

Document Has Been Signed on 10/02/2025 12:12 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:LOLA SENIOR GUEST HOMEFACILITY NUMBER:
306006096
ADMINISTRATOR/
DIRECTOR:		DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:8681 LOLA AVENUETELEPHONE:
(714) 300-4540
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 6CENSUS: 5DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:00 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 the visit, all residents were observed in their room during the visit, except one resident who was observed watching television. There’s a total of 6 bedrooms and 4 bathroom areas. There’s a living room space, a dining space and a detached 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 measured in between 105.2 – 106.5 degrees F. Kitchen: 4 of 4 burners and the warmer are operational on the gas stove. Sharps are kept locked in the a kitchen drawer. Cleaning chemicals are stored below the sink in a locked cabinet. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

Client & Staff Files: Resident and staff files stored in locked filing cabinets near a dining table below the facility postings board.
File Review: 3 of 5 resident files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Resident medications and the first aid kit are stored in the locked filing cabinets near the dining table.


Medication Review: 3 of 5 resident medications were reviewed during the visit. Discrepancies were noted and photos were taken.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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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Document Has Been Signed on 10/02/2025 12:12 PM - It Cannot Be Edited


Created By: Jerome Haley On 09/30/2025 at 02:07 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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

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 for resident 1 (R1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator Dinh will email a request for an exemption for Resident 1. Including all required hospice information.
Type A
Section Cited
CCR
87633(f)(1)
Hospice Care for Terminally Ill Residents
(1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for Resident 1 (R1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator Dinh will email LPA proof of training provided to facility staff by the Hospice provider caring for R1's G Tube. Including the relevant information on the skilled professional who provided the training for facility staff.
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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2025 12:12 PM - It Cannot Be Edited


Created By: Jerome Haley On 09/30/2025 at 02:45 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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medications 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 unsecured noon time and pm medications were observed sitting on top of the medication storage area accessible to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator Dinh will conduct an in service training on medication administration and storage for all staff listed on the personnel report. Administrator Dinh will email LPA a training certificate for each staff who competed the training.
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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096
VISIT DATE: 09/30/2025
NARRATIVE
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Linens & Hygiene Supplies: Hygiene items were observed in the resident bathrooms locked below the sink and additional hygiene items were observed in the laundry room.

Garage Area: The garage is used as a storage space for various supplies. Incontinent care supplies, walkers, clothing, surgical mask and an additional water supply was observed.

Backyard/Exterior:. Walkways are free of obstruction. A table and chairs were observed under a patio area.

Bodies of Water: Swimming pool is surrounded by a self-latching fence that measured five feet high off the ground.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.

Fire Extinguisher: Fire extinguisher was observed mounted in the kitchen and in the dining room near the locked medication, and locked staff and resident files.

An emergency evacuation drill: An emergency evacuation drill was conducted September 10, 2025.

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


Facility postings are posted are available for review on the main postings board above the locked filing cabinets where medications, and staff, and resident files are stored.

Additional Comments: Licensing fees are current. Interviews with staff were conducted A resident interview was conducted. Facility contact information was reviewed, updated, and confirmed during the visit.

Deficiencies are being cited as a result of today’s annual inspection.

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: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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