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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006342
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:56:00 PM

Document Has Been Signed on 09/18/2025 04:56 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:MARIGOLD BOARD AND CAREFACILITY NUMBER:
306006342
ADMINISTRATOR/
DIRECTOR:		TRANAE QUATICE GATLINFACILITY TYPE:
740
ADDRESS:8601 SAN ROMOLO WAYTELEPHONE:
(661) 236-6787
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
09/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Trenae QuaticeTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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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, one of which may be bedridden. As of today, the facility has five residents admitted to the facility. Four residents were present during the visit. There’s a total of 4 bedrooms, 3 of which are for residents. One bedroom is being used as an office space. There are two restrooms, one for residents and one for staff. The staff restroom is locked, but can be used by residents. There’s a living room space, a dining space and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, sink, and tub/shower. Grab bars are tightly secured to the wall. Hot water measured at 113.7 degrees F. Kitchen: 4 of 4 burners were operational on the gas stove. Sharps are kept locked in the medication cabinet next to the refrigerator. Cleaning solutions are stored in a locked cabinet below the sink. 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 a locked cabinet in the staff office room.
File Review: 3 of 5 resident files were reviewed during the visit, and 3 staff files were reviewed.

of 5 resident medications were reviewed during the visit.



Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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 3
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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342
VISIT DATE: 09/18/2025
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Medications/First-Aid Kit: Resident medications are stored in a locked medication cabinet in the kitchen.
Medication Review: 3 of 5 resident medications were reviewed during the visit.

Linens & Hygiene Supplies: Hygiene items were observed in the main hallway cabinet with a supply of clean linens. An additional linen supply was observed in the staff office.

Garage Area: The garage is organized and used mainly as a storage area. A washer and dryer was observed. An additional refrigerator was observed. Miscellaneous facility items were observed: matts, walker, and incontinent care supplies to name a few of the items observed. An emergency supply of water and emergency food was observed.

Backyard/Exterior: The backyard is organized. Walkways are free of obstruction. A table with some chairs was observed under a shaded patio area. A storage shed used to store facility items like walkers, and wheelchairs was observed.
Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguisher was observed mounted on a wall in the main hallway and inside the garage near the door to enter the kitchen area.
An emergency evacuation drill: June 30, 2025. Evacuation drills are conducted quarterly.

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


Several facility postings are posted, and available for review on the main postings wall as soon as you enter the facility.

Additional Comments: Licensing fees are past due. LPA called the licensee during the inspection in regards to the licensing fees. LPA was expecting a call back before the end of the visit. LPA will follow up with licensee regarding the annual fees. During the visit, 3 of 5 resident files were reviewed, and medications were reviewed for 3 of 6 residents. 3 staff files were reviewed during the visit. Facility telephone number and the additional contact information was confirmed during the visit

No deficiencies are being cited during today’s visit.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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