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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006313
Report Date: 09/23/2025
Date Signed: 09/23/2025 04:48:26 PM

Document Has Been Signed on 09/23/2025 04:48 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 OF YOUTH SENIOR LIVINGFACILITY NUMBER:
306006313
ADMINISTRATOR/
DIRECTOR:		JERRAR, MOE A.FACILITY TYPE:
740
ADDRESS:525 N CAROUSEL PLACETELEPHONE:
(657) 208-3199
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
09/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:House manager Brianna BernalTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On September 23, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted the House Manager (HM) Brianna Bernal about the visit. For this visit, there are two staff members on duty, both of which are background cleared and associated. HM later arrived to assist with the inspection.

The PUB475 ‘See Something, Say Something’ poster was observed to be located by the front entrance. LPA observed the Administrator's Certificate for Moe Jerrar, which expires on July 20, 2026.

The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, five of which may be non-ambulatory, one of which may be bedridden, and six of which may be on hospice. LPA toured the interior and exterior portions of the facility with HM. For this visit, there are a total of four non-ambulatory and one ambulatory residents in care, none of which is on hospice, and one is bedridden.

The facility is a single-story home. There are a total of six bedrooms, five of which are private resident rooms, and one serves as staff quarters. LPA toured each bedroom with the HM and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and free of any hazards. LPA observed the staff quarters to be kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of three bathrooms.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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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Document Has Been Signed on 09/23/2025 04:48 PM - It Cannot Be Edited


Created By: Garlli Tat On 09/23/2025 at 03:57 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, there were expired food items, mainly canned tomatoes (Hunt) and peanut butter (Skippy) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Licensee will dispose of expired food items and review pantry for expired food on a weekly basis. House manager disposed of peanut butter during the visit. Deficiency cleared.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of five persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Licensee will provide a copy of the Physician's Report for Resident 4.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2025 04:48 PM - It Cannot Be Edited


Created By: Garlli Tat On 09/23/2025 at 03:57 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(2)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not provide documentation of resident's refuse to see a Primary Care Physician (PCP) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Licensee will provide a signed copy of documentation indicating resident's refusal to see a PCP and send it to CCLD by 09/30/2025.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not possess a signed Admission Agreement for Resident 1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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Licensee will provide CCLD a signed copy of the Admission Agreement for Fountain of Youth Senior Living by 09/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Garlli Tat
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2025


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: FOUNTAIN OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313
VISIT DATE: 09/23/2025
NARRATIVE
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Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be between 105.2 and 109.5 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked in the kitchen and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the living room. Fire extinguishers were dated and tagged on April 29, 2025. LPA observed the emergency disaster and evacuation plan, which is posted by the front entrance. Facility had back-up emergency food and water supply, located in the pantry. LPA observed that the First Aid kit had all the required components. Medications and toxins were also observed to be locked in a cabinet in the kitchen, inaccessible to residents in care.



For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards or obstructions. There are two self-latching gates in the backyard that can be opened in case of an emergency. No bodies of water were observed.

Five client records and three staff records were reviewed during this visit.

Based on today's observations, there are four deficiencies being cited per Title 22 of the California Code of Regulations. A Technical Violation (TV) and a Technical Advisory (TA) were also cited.

An exit interview was conducted with Brianna Bernal. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Right were reviewed.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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