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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006496
Report Date: 01/07/2026
Date Signed: 01/07/2026 06:24:49 PM

Document Has Been Signed on 01/07/2026 06:24 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HOME AT CASCADE LANE, INC.FACILITY NUMBER:
306006496
ADMINISTRATOR/
DIRECTOR:		AVILA, MARIA JASMINFACILITY TYPE:
740
ADDRESS:15311 CASCADE LANETELEPHONE:
(714) 515-0459
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 6DATE:
01/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Jasmin Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
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On January 7, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced Case Management visit for the purpose of issuing deficiencies. LPA was greeted and granted entry after stating the purpose of the visit to staff. Administrator Jasmin Garcia was contacted and arrived shortly to assist with the visit.

Per review of staff files, the facility did not maintain staff records for Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). Additionally S2 and S3 did not obtain their initial 40-hour training. LPA observed that the licensee did not maintain personnel records for S1, S2, and S3's personnel records and were incomplete.

Deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted Administrator Jasmin Garcia, and a copy of this report, LIC809-D, and LIC811 were provided at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2026
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 01/07/2026 06:24 PM - It Cannot Be Edited


Created By: Eboni Bentley On 01/07/2026 at 05:07 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: HOME AT CASCADE LANE, INC.
FACILITY NUMBER: 306006496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
HSC
1569.625

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1569.625(b) (1) The department shall adopt regulations to require staff members of residential care facilities for residents ...... to receive appropriate training. This training shall consist of 40 hours of training.
This requirement is not met as evidenced by:
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The administrator stated they will provide 40 hours Initial training to Staff #2, and Staff #3 by POC due date and send proof to CCLD via email to eboni.bentley@dss.ca.gov by February 6, 2026.
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Based on observation, interview, and record review, the facility does not have a record of Staff #2-3 receiving initial training, which is a potential risk to persons in care.
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Type B
02/06/2026
Section Cited
CCR87412

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87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:...
This requirement is not met as evidenced by:
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The administrator stated they will ensure all personnel records are complete and available for the Department review by POC due date and will send proof to CCLD via email to eboni.bentley@dss.ca.gov by February 6, 2026.
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Based on observation, interview, and record review, the facility does not have a record of Staff #1-3 personnel records, which is a potential risk to persons in care. LPA observed three out of three incomplete personnel records containing LIC 501 only.
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2026


LIC809 (FAS) - (06/04)
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