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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006623
Report Date: 06/19/2025
Date Signed: 06/19/2025 04:24:20 PM

Document Has Been Signed on 06/19/2025 04:24 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:LOVING HOME CARE HBFACILITY NUMBER:
306006623
ADMINISTRATOR/
DIRECTOR:		TRUONG, PHUOCFACILITY TYPE:
740
ADDRESS:17659 SAN SIMEON STTELEPHONE:
(714) 580-6839
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 0DATE:
06/19/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Licensee - Tin LeTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On June 19, 2025 at 10:45am, Licensing Program Analysts (LPAs) Eboni Bentley and Jessica Cho arrived announced for the purpose of conducting the Pre-Licensing visit for an Initial Application. LPAs conducted the visit with Applicant/Chief Executive Officer (CEO) Tin Le and family member Brian Conseco. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on August 19, 2024 for age range 60 and over.

LPAs toured the facility's indoor and outdoor physical plant with Applicant Tin Le and family member Brian Conseco. Please note that the Applicant is currently residing at the facility and expressed intent to relocate and use facility solely for residents with the date of move being unknown at this time.
The following were observed:

Structure:
The facility is a single-story property in a residential neighborhood comprised of four resident bedrooms with two resident full bathrooms, of which one bathroom is in the master resident bedroom. Currently, the master bedroom is occupied by the applicant. All bedrooms will be for resident use. LPAs observed all common areas which includes the living room, dining area, kitchen, and an attached two car garage which doubles as a laundry area.

Telephone Number:
Facility does not currently have a land line.

CONTINUE TO LIC809-C ....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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: LOVING HOME CARE HB
FACILITY NUMBER: 306006623
VISIT DATE: 06/19/2025
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Liability Insurance:
Facility does not currently have liability insurance.

Signal System:
No signal system.

Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings. All rooms and closets contained personal items belonging to the applicant and will be removed and ready for resident use.

Bathrooms: Bathrooms were clean and operational with slip resistant mats in place. Grab bars were not present.

Linens and Hygiene Supplies:
Clean linens were fully stocked however the hygiene supplies for resident use were not observed.

Appliances:
Stove burners, microwaves, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site.

Medication:
Medication will be secured in a closet by the garage.

Reading Material, Games, Equipment, & Materials:

The facility maintains games and activities in the living room area.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: LOVING HOME CARE HB
FACILITY NUMBER: 306006623
VISIT DATE: 06/19/2025
NARRATIVE
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Emergency Phone Numbers/Exit Plan:

Posted on the bulletin boards.

Postings:

The See Something, Say Something (PUB475) was in the correct size and the Ombudsman Posters were posted by the entry way as well as the Rights of the Resident Councils, Resident's Rights, and Theft & Loss Policy. The Activity Schedule, Food Menu, and a copy of the Admission Agreement was missing.

Food Service and Menu:

Supply of seven-day non-perishable and two-day perishables were observed in the kitchen cabinet and garage. The emergency food/water supply were also available in the garage.

Smoke and Carbon Monoxide Detectors:

The smoke detectors and carbon monoxide alert systems were tested and found operational.

Fire Extinguishers:

A fire extinguisher was mounted, fully charged, and serviced on October 8, 2024.

Fire Clearance:

Approved on November 18, 2024 for 6 ambulatory residents.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: LOVING HOME CARE HB
FACILITY NUMBER: 306006623
VISIT DATE: 06/19/2025
NARRATIVE
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Sharps and Toxins:

Sharps were observed to be secured and inaccessible. Cleaning supplies and toxins were observed in the locked garage, and Applicant stated they plan to relocate all to a locked cabinet in the garage.

Water Temperature:

The water temperature in the two resident bathrooms measured at 103.8 and 107.2 degrees Fahrenheit.

Medications, First Aid Kit, & Manual:

The First Aid Kit and manual were checked and found to be in order.

Component III:

Component III was waived because Applicant is operating other licensed facilities and has fulfilled this requirement.

The following items require correction:

· Clear passageway (soil/hose) in the yard

· Install grab bars in the resident bathrooms

· Ensure all medications, sharps (gardening tools, scissors), and toxins (cleaning solutions) are inaccessible and secured at all times

· Ensure that the home/resident’s bedroom spaces are de-cluttered and ready for use

· Ensure all emergency supplies which include but are not limited to such as whistles are obtained per the Emergency Disaster Plan (LIC610E)

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: LOVING HOME CARE HB
FACILITY NUMBER: 306006623
VISIT DATE: 06/19/2025
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·Amend the LIC610E reflecting the type of residents served

· Missing postings- food menu, activity calendar, sign in and out area, and admission agreement.

· Submit proof of liability insurance policy

Based on today’s observation, the facility is not ready for licensure. A subsequent visit will be conducted to review the corrections some time towards the end of the year and Applicant will contact the department if an extension is needed or when the inspection date is requested.

An exit interview was conducted with Applicant Tin Le and family member Brian Canseco, and a copy of this report was 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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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