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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006369
Report Date: 03/30/2026
Date Signed: 03/30/2026 09:42:24 AM

Document Has Been Signed on 03/30/2026 09:42 AM - 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:HILLS OF GOWDY, THEFACILITY NUMBER:
306006369
ADMINISTRATOR/
DIRECTOR:		SO, BRYANTFACILITY TYPE:
740
ADDRESS:23981 GOWDY AVENUETELEPHONE:
(714) 430-7672
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
03/30/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Spoke with Eleazar "Eli" Cuyson via phoneTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management Visit and a resident health and safety check. LPA was greeted and granted entry by Staff #1 (S1) at 8am. The facility has a census of four residents.

The exterior of the facility is overgrown with weeds and palm tree fronds. LPA inquired if a gardener was maintaining the property but at this time, there is no gardener. A Type B deficiency will be given for 87303(a) Maintenance and Operation. The facility temperature was 73 degrees and all utilities are in working order. LPA toured the kitchen and observed the refrigerator has a two day supply of perishable items and there is seven days of non-perishable items on hand.

LPA inspected the hot water temperature of two of three bathrooms. The hot water temperature ranged from 92.7 to 93.2 degrees Fahrenheit. A Type A deficiency and $250 Immediate Civil Penalty will be assessed for 87303(e)(2) Maintenance and Operation for hot water temperatures not being within range of 105 to 120 degrees Fahrenheit.

LPA interviewed three of four residents and LPA observed residents were clean, dressed and were eating breakfast, or waiting for breakfast. LPA interviewed two of two staff members who both have been partially paid from 2/19-3/15/2026. Staff are not sure when the second half will be paid from this pay period since the pay periods are now weekly. Two of two staff confirmed they were paid from 3/3-3/18/2026. One staff member's check has cleared, the second staff member stated the check is pending in the bank and will clear on 3/30/2026. A Civil Penalty has been issued for 87213 Finances from March 12, 2026 to March 30, 2026. The amount assessed is $100/day X 19 days for a total amount of $1900.

(Continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2026
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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Document Has Been Signed on 03/30/2026 09:42 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 03/30/2026 at 08:58 AM
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: HILLS OF GOWDY, THE
FACILITY NUMBER: 306006369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
87303(e)(2)

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87303 (e) Water supplies and plumbing fixtures shall be maintained as follows:
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained.. to attain a temperature of not less than 105 degree F (41 degree C)
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Licensee to adjust water temperature and forward proof to LPA by POC due date.
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and not more than 120 degree F (49 degree C).This requirement is not met as evidenced by: Based on LPA observations and interviews Licensee failed to ensue water temperature is between 105 and 120 degrees F which poses an immediate health and safety risk to residents in care.
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/30/2026 09:42 AM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 03/30/2026 at 09:08 AM
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: HILLS OF GOWDY, THE
FACILITY NUMBER: 306006369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2026
Section Cited
CCR
87303(a)

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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is
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Administrator will follow-up to obtain gardening services by POC due date. LPA will continue to monitor.
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not met as evidenced by: Based on LPA observations and interviews, the facility exterior is overgrown with weeds and palm tree fronds obstruct walkways. This poses a potential health and safety risk for residents, staff and visitors visiting the facility.
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: HILLS OF GOWDY, THE
FACILITY NUMBER: 306006369
VISIT DATE: 03/30/2026
NARRATIVE
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(Continued from LIC 809)

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and Health and Safety Code. Civil Penalties are being assessed for Failure to Correct/Repeat Violation at $100 per day X 19 days for finances and a $250 Immediate Civil Penalty for hot water temperatures Total assessed is $2150.

An exit interview was conducted with Staff #1 and AD via phone. AD gave permission for Staff #1 (S1) to sign licensing reports. A copy of this report was given to the facility along with a copy of the LIC 809-Ds. LIC 421-FCs and Appeal RIghts.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC809 (FAS) - (06/04)
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