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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006311
Report Date: 06/11/2025
Date Signed: 06/11/2025 12:47:13 PM

Document Has Been Signed on 06/11/2025 12:47 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:KAYLA'S BOARD & CAREFACILITY NUMBER:
306006311
ADMINISTRATOR/
DIRECTOR:		RINGOR, ELVIE B.FACILITY TYPE:
740
ADDRESS:6593 E CALLE DEL NORTETELEPHONE:
(714) 600-7269
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 3DATE:
06/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Elvie RingorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On June 11, 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) Leticia Bitas. Administrator (AD) Elvie Ringor met with LPA and was present during the visit. AD Elvie Ringor has an administrator certificate with an expiration date of September 5, 2026.

The facility is a single level structure, licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden and has a hospice waiver for six (6) residents. The home consists of the following: Four (4) resident bedrooms, one (1) staff bedrooms, three (3) bathrooms, a living room area, dining room area, kitchen, outdoor shaded seating area, and an attached two car garage.

There are three residents on census, all present during today’s visit. LPA obtained copies of pertinent documents, including facility records, clients/staff rosters, Personnel Record (LIC500), and clients/staff records.

During the visit, LPA Bentley toured the interior and exterior of the physical plant with AD Ringor 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 in good condition, adequate lighting was provided, storage for
each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately
stocked at the time of visit.

CONTINUE TO LIC809-C PAGE
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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: KAYLA'S BOARD & CARE
FACILITY NUMBER: 306006311
VISIT DATE: 06/11/2025
NARRATIVE
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Bathrooms were found to be clean and operational. The water temperatures in three bathrooms measured 106.1 degrees F and 114.9 degrees F. A comfortable temperature of 74 degrees F was maintained throughout the facility.

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 stored and locked. 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 with two refrigerators and additional supply of perishable items. The washer and dryer were observed to be in working condition. Facility has emergency food supply and water supply. The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs was observed.

Emergency safety drills was last conducted on July 15, 2019 and a deficiency is being cited. First aid kit is maintained and contains all the necessary elements. Smoke and carbon monoxide alarms were tested and observed operational. The facility has two (2) fire extinguishers that are fully charged in the kitchen and garage, with a last service date of October 22, 2024. A working telephone (714-600-7269) remains available. Liability Insurance is effective June 30, 2024 through June 30, 2025 and licensee also provided documentation for Liability Insurance is effective June 30, 2025 through June 30, 2026.

LPA Bentley conducted an audit of three (3) resident files (R1-R3) and four (4) staff files (S1-S4). A review of the Medication and Medication Administration Record (MAR) was conducted. LPA observed annual training missing for three out of four staff files. Upon review of Resident #1 (R1) centrally stored medication list and medication box, four refills are not present in facility. Licensee stated refills were requested on June 9, 2025 but have not been delivered. Interviews were conducted with three (3) residents and two (2) staff.

Based on today’s observations, deficiencies are being cited 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 Elvie Ringor.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 12:47 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/11/2025 at 12:18 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: KAYLA'S BOARD & CARE
FACILITY NUMBER: 306006311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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, which poses an immediate safety risk to persons in care. LPA observed records of last fire, emergency, and disaster drill conducted on July 15, 2019. No drills have been conducted since that date.
POC Due Date: 06/12/2025
Plan of Correction
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Licensee stated they will conduct an emergency disaster drill immediately and submit proof to LPA by POC due date. Licensee will conduct emergency disaster drills quarterly moving forward.
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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 12:47 PM - It Cannot Be Edited


Created By: Eboni Bentley On 06/11/2025 at 12:18 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: KAYLA'S BOARD & CARE
FACILITY NUMBER: 306006311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025

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 record review, the licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care. LPA observed three out of four personnel files missing annual staff training on postural supports, restricted health conditions, dementia, and hospice care.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee agrees to conduct training with all staff and will submit proof of correction to LPA/CCLD email at eboni.bentley@dss.ca.gov by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above, which poses a potential health, safety and personal rights risk to persons in care. Based on record review, LPA observed that Resident #1, Resident #2, and Resident #3 do not have Pre-Appraisals and annual Needs and Services plans.
POC Due Date: 06/19/2025
Plan of Correction
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Licensee agrees to complete updated Appraisal/Needs and Service Plans for Resident #1, Resident #2, and Resident #3, and will submit proof of correction to LPA/CCLD email at eboni.bentley@dss.ca.gov 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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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