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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006442
Report Date: 08/15/2025
Date Signed: 08/15/2025 03:52:17 PM

Document Has Been Signed on 08/15/2025 03:52 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARE CELINE 2FACILITY NUMBER:
306006442
ADMINISTRATOR/
DIRECTOR:		AGUILA, CHERRYFACILITY TYPE:
740
ADDRESS:606 ALCOTT AVENUETELEPHONE:
(714) 801-5208
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
08/15/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Dolores "Dory" LacwasanTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Dory Lacwasan. and the purpose of the inspection was discussed. Administrator (AD) Cherry Aguila was contacted by phone and arrived at approximately 3:00 p.m.

LPA is following up regarding deficiencies previously cited on June 20, 2025, during facility's annual/required inspection. Deficiency 1569.625(b)(1) was cited due to one of two staff records not containing documentation consisting of completed 20 hour required staff training. Deficiency 1569.69(a)(2) was cited due to two of two staff files not including documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training or instruction. Deficiency 1569.695(c) was cited due to emergency drills not being conducted. Deficiency 87307(a) was cited due to staff residing at the facility and spending the night on the living room couch. Deficiency 87307(a)(2)(C) was cited due to a bathroom located within a resident's bedroom being used as the staff bathroom.

AD provided LPA with completed 20 hours, including six hours specific to dementia care, four hours specific to postural supports, restricted health conditions, and hospice care for staff via email on August 15, 2025. On the same email, AD provided documentation of completed 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training instruction. On July 7, 2025, AD provided LPA with documentation for disaster drill held on July 2, 2025, it included the date, the type of emergency covered by the drill, and the names of staff participating in the drill via email.

(Cont. LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2025
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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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE CELINE 2
FACILITY NUMBER: 306006442
VISIT DATE: 08/15/2025
NARRATIVE
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During today’s visit, LPA observed facility to be at maximum capacity with four of four facility bedrooms currently occupied by residents. In the hallway storage, LPA observed the same dresser and personal items, including clothing and hygiene items previously observed during annual visit on June 20, 2025. Staff Lacwasan confirmed they continue residing at the facility and sleeping on the couch; a Deficiency was cited on today’s date. LPA also observed staff continue to use the master bedroom bathroom located within a resident's bedroom as the staff bathroom; a Deficiency was cited on today’s date.

Three of five deficiencies previously cited have been cleared.

Based on observations made during today’s inspection, deficiencies are being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Claudia Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2025 03:52 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 08/15/2025 at 03:26 PM
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: CARE CELINE 2
FACILITY NUMBER: 306006442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2025
Section Cited
CCR
87307(a)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff...

This requirement is not met as evidenced by:
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AD stated staff will remove personal belongings and no longer live on-site, spend the night, or sleep on the livng room couch and picture proof provided to LPA via email by POC date.
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Based on observation and staff interview, the licensee did not comply with the section cited above as the facility does not have a staff room and staff is residing at the facility and sleeping on the living room couch, which poses a potential personal rights risk to persons in care.
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Type B
09/12/2025
Section Cited
CCR87307(a)(2)(C)

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(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
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AD stated the bathroom located with the residents' bedroom will no longer be used as the staff bathroom. AD stated an in-service will be held to ensure all staff is aware and proof will be provided to LPA via email by POC date.
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Based on observation and staff interview, the licensee did not comply with the section cited above as the master bedroom bathroom located within a resident's bedroom is currently used as the staff bathroom, which poses a potential personal rights risk to persons 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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2025


LIC809 (FAS) - (06/04)
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