306006369-4-21-2026-22-AS-RMRT-DTCMG5-20260421093521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006369
Report Date: 04/21/2026
Date Signed: 04/21/2026 09:35:30 AM

Document Has Been Signed on 04/21/2026 09:35 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, THE		FACILITY NUMBER:	306006369
ADMINISTRATOR/ DIRECTOR:	SO, BRYANT		FACILITY TYPE:	740
ADDRESS:	23981 GOWDY AVENUE		TELEPHONE:	(714) 430-7672
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 5	DATE:	04/21/2026
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Staff #3 for Eli Cuyson, Administrator		TIME VISIT/ INSPECTION COMPLETED:	09:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management Visit and conducted a resident health and safety check. LPA was greeted and granted entry at 8:15am by Staff #2. LPA spoke with Administrator (AD) Eli Cuyson via phone and explained the purpose of the visit. Upon entry LPA observed one resident eating breakfast and another just finishing breakfast and reclining on the sofa. There were five residents in care and three staff members on site. LPA observed the facility temperature to be 70 degrees Fahrenheit and staff was preparing breakfast for the other residents. The exterior of the property was not maintained but has been cited. The Plan of Correction is due at the end of the month. During the visit, LPA toured the kitchen and observed the freezers and pantries had seven days of non-perishable supplies and the refrigerator had two days of perishable food items. Staff was cooking breakfast and feeding residents. Utilities have remained on and appliances are in working order. LPA measured hot water temperatures in two of three resident bathrooms. The hot water temperatures ranged between 105.0 to 105.2 degrees Fahrenheit. LPA was informed the water heater has been replaced and observed a hot water temperature log in bathrooms. LPA checked on the additional three residents. One was drinking their breakfast shake in their room, another resident was in the bathroom and the third resident was asleep in their bedroom. Residents were being cleaned and dressed for the day. LPA interviewed two of five residents and three of three staff. Three of three staff members reported they are paid timely and are not owed any back pay. Staff are now paid on a weekly basis. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

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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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: 04/21/2026

NARRATIVE

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(Continued from LIC 809)

LPA spoke with Administrator (AD) and relayed that, although staff are now being paid timely and are current, the Plan of Correction states that the Licensee is to submit a financial plan to ensure that staff receive their pay that is due, and for pay periods moving forward. On this date, a financial plan has not been received by the Department. A civil penalty is assessed for the dates of 3/31/26 to 4/21/2026 for a total of 22 days X $100 per day. Total assessed for 87213 Finances is $2200.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Staff #3 for AD Eli Cuyson, and a copy of this report was given to the facility along with a copy of the LIC421-FC,

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

LIC809 (FAS) - (06/04)

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