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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006416
Report Date: 03/03/2026
Date Signed: 03/03/2026 11:50:10 AM

Document Has Been Signed on 03/03/2026 11:50 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:ABUNDANT GRACE CARE VILLAFACILITY NUMBER:
306006416
ADMINISTRATOR/
DIRECTOR:		DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:9672 COLONY STREETTELEPHONE:
(657) 201-3142
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
03/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Theresa Dompreh-MensahTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conducted the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Theresa Dompreh-Mensah and discussed the purpose of the visit. The facility currently has 5 residents in care.

The facility is a one story home with three resident bedrooms, two resident bathrooms, one caregiver room, one caregiver bathroom, living room, kitchen, dining room and attached two car garage. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed a fresh supply of linens in the closet located in the hall by the resident rooms. LPA observed the bathrooms to have toilet paper, paper towels and texture shower flooring. LPA observed the caregiver room to be clean and free of medications and toxins. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day non perishable supply on hand. LPA advised AD that they are at the minimum supply to meet regulatory requirements and advised that more groceries need to be purchased as to not go below what is required to maintain compliance. The medications are locked and stored in a kitchen cabinet making them inaccessible to residents in care. The knives and sharps are locked in a kitchen drawer by the sink making them inaccessible to residents in care. Toxins and chemicals are locked under the kitchen sink making them inaccessible to residents in care. LPA observed a fire extinguisher charged and with a service date of December 1, 2025, mounted to the wall next to the See Something Say Something poster in the living room by the entrance of the kitchen. LPA observed the garage to be locked and made inaccessible to residents in care. The emergency food and water supply was observed in the garage cabinets. LPA observed a shaded seating area for resident use and no debris or obstructions were observed on the outside of the facility. Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2026
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 6
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: ABUNDANT GRACE CARE VILLA
FACILITY NUMBER: 306006416
VISIT DATE: 03/03/2026
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AD tested the carbon monoxide and smoke detectors and they were found to be operational.

LPA reviewed staff records and no discrepancies were observed. LPA reviewed resident records and observed 3 of 5 residents do not have bed rail orders for the half bed rails that were observed during the tour of the facility. LPA reviewed the emergency disaster plan has not been reviewed/updated and does not include newer staff. LPA reviewed the last disaster drill was conducted on February 1, 2026. LPA reviewed resident medications and no discrepancies were observed. All staff present are background cleared and associated to the facility.

Based on today’s inspection a deficiency along with technical violation and advisory are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D, LIC858, technical violation, advisory, and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 03/03/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/03/2026 11:50 AM - It Cannot Be Edited


Created By: Hanna Gough On 03/03/2026 at 11:26 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: ABUNDANT GRACE CARE VILLA
FACILITY NUMBER: 306006416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 in 3 of 5 residents having half bed rails with no physicians orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee stated they will obtain the orders and send proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


LIC809 (FAS) - (06/04)
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