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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006280
Report Date: 05/23/2025
Date Signed: 05/23/2025 07:08:28 PM

Document Has Been Signed on 05/23/2025 07:08 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:SHASTA RESIDENTIAL CAREFACILITY NUMBER:
306006280
ADMINISTRATOR/
DIRECTOR:		DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:16274 SHASTA STTELEPHONE:
(714) 300-4540
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
05/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee/Adminstrator - Kevin DinhTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On May 23, 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 Caregiver (CG) Allen Jao. Administrator (AD) Kevin Dinh was contacted via telephone and arrived at the facility a short time later. AD Kevin Dinh has an administrator certificate with an expiration date of 10/15/2025.

The facility is a single level structure, licensed for six (6) non-ambulatory residents of which on may be bedridden and a hospice waiver for six (6) residents. The home consists of the following: Four (4) resident bedrooms, three (3) bathrooms, living room area, dining area, kitchen, outdoor covered patio seating area, and an attached two car garage.

During the visit, LPA Bentley toured the interior and exterior of the physical plant with CG Jao and AD Dinh and the following was observed: There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were available, lighting was provided, and storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperatures in three bathrooms measured 109.7 degrees F to 114.6 degrees F. A comfortable temperature of 73 degrees F was maintained throughout the facility.

CONTINUE TO LIC809-C PAGE
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280
VISIT DATE: 05/23/2025
NARRATIVE
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LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharps objects were not securely stored and locked and a deficiency is being cited. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available.

There is a two car garage that as two three entry points of which two out of three was kept unlocked throughout the inspection. There is a refrigerator in the garage with an additional supply of perishable items and resident medication found stored inside, unlocked at the time of the visit, for which a deficiency is being sited. The washer and dryer were observed to be in working condition. Facility has emergency food supply and water supply. A covered patio area with tables and chairs was observed. The backyard and front yard were found unkept and not well maintained. A technical violation was issued for the yards and a screen door on the garage door, found with holes and in disrepair.

Emergency safety drill was last conducted on March 10, 2025 and are conducted quarterly. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were tested and observed operational. A working telephone (714-798-7218) remains available, and the facility has a device that can be used for video teleconference purposes. The facility has one (1) fire extinguisher in the kitchen that was charged and last serviced on March 21, 2025. Liability Insurance is effective September 15, 2024 through September 15, 2025.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), conducted three (3) staff interviews, and five (5) resident interviews. A review of the Medication and Medication Administration Record (MAR) was conducted.

Based on today’s observations, four deficiencies and a technical violation were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, deficiency pages, and appeal rights were provided to Administrator Kevin Dinh.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/23/2025 07:08 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/23/2025 at 03:24 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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 three out of three bathrooms and garage cabinet where toxins were found unlocked. LPA also observed caregiver leave kitchen with sharps in kitchen drawer unlocked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Facility staff locked up the toxins and sharps during the inspection. LIcensee stated they will re-train the facility staff on safely storing chemicals and sharps. 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 on POC due date.
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 oberservation and interview, the licensee did not comply with the section cited above three out of six residents medications, which poses an immediate health and safety risk to persons in care. LPA observed three different residents medications unlocked. Multiple medications in Resident #1 (R1) drawers, three medications in an unlocked refrigerator in the unlocked garage for Resident #2 (R2), and on in a common area in the living room for Resident #3 (R3).
POC Due Date: 05/24/2025
Plan of Correction
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Facility staff locked up all medications during the inspection. LIcensee stated they will re-train the facility staff on safely storing 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.
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: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2025 07:08 PM - It Cannot Be Edited


Created By: Eboni Bentley On 05/23/2025 at 03:24 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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 which poses an potential safety and personal rights risk to persons in care. Bedroom # 1, occupied by two residents Resident #3 (R3) and Resident #4 (R4) with clearance for single resident occupancy. Bedroom #3, occupied by two staff Staff #1 (S1) and Staff #2 (S2), is approved fire clearance for single resident occupancy bedroom.
POC Due Date: 05/30/2025
Plan of Correction
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Licensee stated they will submit a written plan when fire clearance facility sketch for Bedroom #1 and Bedroom #3 will be requested and conducted. LIcensee stated they will provide picture to CCLD via email by POC date.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as a bed and staff's personal belongings were observed in the living room with curtain hanging from ceiling. Staff indicated they sleep onsite in the living room area, which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
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Licensee removed the bed and staff's personal belongings during the visit and stated staff will no longer sleep in the living room. LIcensee stated they will provide letter stating changes and picture of living room to CCLD via email by POC 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: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
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