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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006397
Report Date: 03/10/2025
Date Signed: 03/10/2025 11:36:27 AM

Document Has Been Signed on 03/10/2025 11:36 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:ARISE HOMES 2FACILITY NUMBER:
306006397
ADMINISTRATOR/
DIRECTOR:		CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:23232 LA VACA ST.TELEPHONE:
(949) 446-4584
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Rowena CarrilloTIME VISIT/
INSPECTION COMPLETED:
11:51 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Rowena Carrillo was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Rowena Carrillo has a valid Administrator certificate which expires on June 24, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, one of which may be bedridden, and has a hospice waiver for six. The facility is a single story home with five resident bedrooms, one of which can be shared, one staff bedroom, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed three residents in care, one of which is on hospice, and two care giving staff present. LPA observed residents eating breakfast in the dining room and relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the dining room. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 132.2 and 134.6 degrees Fahrenheit. LPA observed the staff room to be free of hazards.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The six burner gas stove lights unassisted. LPA observed knives and sharps to be stored in a locked kitchen cabinet. LPA observed the facility has a three day emergency food and water supply stored in the kitchen. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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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: ARISE HOMES 2
FACILITY NUMBER: 306006397
VISIT DATE: 03/10/2025
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Fire extinguishers are located in the entryway of the facility, in the resident hallway, and in the two car garage. Fire extinguishers were observed to be charged and up to date on service. LPA tested the wired smoke detectors which tested operational. LPA tested the individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on October 19, 2024. LPA observed a fire place in the living room and it was observed to not be in operation at the time of visit. The centrally stored medication is kept in a locked cabinet in the kitchen. A First Aid kit was observed be stored in the locked cabinet and it was observed to have all the required components. The door leading to the laundry room is kept locked and inaccessible to residents in care. LPA observed chemicals and toxins to be stored in in the laundry room. LPA observed additional linens to be stored in the laundry room. The door leading to the attached two car garage is kept locked and inaccessible to residents. The garage is used for storage.

LPA and the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side of the facility is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all three resident files. LPA observed the facility did not have a Reappraisal on file for Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3). LPA reviewed all three residents’ medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Rowena Carrillo. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/10/2025 11:36 AM - It Cannot Be Edited


Created By: Brandon Lopez On 03/10/2025 at 11:21 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: ARISE HOMES 2
FACILITY NUMBER: 306006397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The hot water temperature for the resident bathrooms measured between 132.2 and 134.6 degrees Fahrenheit.
POC Due Date: 03/24/2025
Plan of Correction
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AD lowered the water temperature at time of visit. AD will create a weekly water temperature log and record the water temperature once it has finished adjusting to the required temperature. AD will submit the water temperature log to LPA via email or fax by POC 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, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility does not have Reappraisals on file for Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3).
POC Due Date: 03/24/2025
Plan of Correction
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AD agreed to complete Reappraisals for R1, R2, and R3. AD will submit the completed Reappraisals for all three residents to LPA via email or fax by POC 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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