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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006161
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:11:15 PM

Document Has Been Signed on 05/30/2025 04:11 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 VALLEY CARE HOME, INCFACILITY NUMBER:
306006161
ADMINISTRATOR/
DIRECTOR:		ARGOSINO, DULCEFACILITY TYPE:
740
ADDRESS:15938 MAIDSTONE STTELEPHONE:
(714) 418-0341
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Dulce ArgosinoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On May 30, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by the administrator, Dulce Argosino and explained the reason for the visit. Facility is licensed for six non-ambulatory residents, with a hospice waiver for six. Currently there are six residents, of which two are on hospice during today's visit. Administrator certificate expires on March 23, 2027.

At 9:35 AM, LPA Bentley, along with the Administrator toured the facility, checked food service, and the first aid kit. The home consists of 5 resident bedrooms, of which one is shared, 1 staff room, 2 full bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 110.6 degrees F. and 114.0 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen was inspected and found clean and sanitary. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients in the garage. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gate is self latching and operational. The backyard has a small garden area.

CONTINUE TO LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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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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 VALLEY CARE HOME, INC
FACILITY NUMBER: 306006161
VISIT DATE: 05/30/2025
NARRATIVE
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Facility provides activities in the form of outdoor activities such as going on walks and exercises. The residents do puzzles such as sudoku, and reading newspapers, books, and magazines. Residents also enjoy watching sports events, news and game shows..

LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The facility’s last fire drill was conducted on March 1, 2025. Emergency food and water supply observed in the garage. First aid kit had all the required elements. Two fire extinguishers are fully charged with a service date of February 5, 2025. A working telephone (714-418-0341) remains available, and the facility has a device that can be used for video teleconference purposes. Liability Insurance is effective June 13, 2024 through June 13, 2025.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), three (3) staff files (S1-S3), and conducted two (2) staff interviews, and six (6) resident interviews. Residents’ medication was found locked and secure and a review of the Medication and Medication Administration Record (MAR) was conducted. LPA observed four out of six residents, Residents #1, Resident #2, Resident #3, and Resident #4 (R1-R4) with medication not listed on MAR. During tour, LPA observed two medications unsecured in Resident #3’s (R3) chest of drawers. LPA observed two oxygen tanks sitting on floor in hallway closet, without rack.


Based on today’s observations, deficiencies are being cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with administrator, Dulce Argosino and a copy of this report LIC809, 809-C, LIC809-D, LIC811, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/30/2025 04:11 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/30/2025 at 01:36 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 VALLEY CARE HOME, INC
FACILITY NUMBER: 306006161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(E)
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on oberservation and interview, the licensee did not comply with the section cited above in two out of four resident oxygen tanks, which poses a potential health and safety risk to persons in care. LPA observed two oxygen tanks sitting on floor in hallway closet, without rack.
POC Due Date: 06/06/2025
Plan of Correction
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LPA observed facility staff call Hospice to request racks during the inspection. During inspection, Licensee provided text response from Hospice company stating racks will be delivered on 6/4/2025. LIcensee stated they will email pictures of oxygen tanks on racks after delivery, to CCLD 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: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 04:11 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/30/2025 at 03:14 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: FOUNTAIN VALLEY CARE HOME, INC
FACILITY NUMBER: 306006161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

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 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, the licensee did not comply with the section cited above in two out of thirteen resident
medications, which poses an immediate health and safety risk to persons in care. LPA observed two medications unlocked
and stored in Resident #3's (R3) bedroom.
POC Due Date: 05/31/2025
Plan of Correction
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Facility staff locked up all medications during the inspection. Licensee stated they will review regulations and re-train the
facility staff on how to safely store resident medications. Licensee stated they will email LPA the content covered in the
training, training attendees and the date and time of training and email to CCLD by 5pm POC due date.
Type A
Section Cited
CCR
87465(h)(6)(A-F)
Incidental Medical and Dental Care Services. Licensee shall be responsible for assuring that a record of centrally stored
prescription medications for each resident is maintained for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the centrally stored medication form & MAR, the licensee did not comply with the section cited above in
four out of six resident records, which poses an immediate health and safety risk to persons in care. Based on Resident
medication and record review, the licensee failed to document R1's, R2's, R3's, and R4's MAR.
POC Due Date: 05/31/2025
Plan of Correction
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Licensee will ensure all resident MARs contain a record of centrally stored medications for all residents in care and sign off on each medication administered, effective immediately. Licensee stated they will review regulations and re-train the facility staff on how to accurately record resident medications. Licensee stated they will email LPA the content covered in the training, training attendees and the date and time of training and email to CCLD by 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:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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