306006630-3-12-2026-22-AS-RMRT-DS4P3Z-20260312105821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006630
Report Date: 03/12/2026
Date Signed: 03/12/2026 11:00:32 AM

Document Has Been Signed on 03/12/2026 11:00 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:	A PLACE LIKE HOME 2		FACILITY NUMBER:	306006630
ADMINISTRATOR/ DIRECTOR:	BEN, SHEILA		FACILITY TYPE:	740
ADDRESS:	14702 KATHY ST		TELEPHONE:	(714) 609-2303
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 6		CENSUS: 5	DATE:	03/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Khatera Bahadory, Administrator Designee		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 (S1) at 8am. LPA met with Administrator Designee (AD) Khatera Bahadory at 9:15am and explained the purpose of the visit. AD shared with LPA that AD recently purchased the facility in February 2026 and the facility will be undergoing a Change of Ownership. The facility is a five bedroom, three bathroom residence with a fire clearance for six non-ambulatory residents in which one may be bedridden in bedroom #2. The facility has a hospice waiver for six residents. Currently there are five residents in care and four were receiving hospice services. LPA toured the kitchen and observed sharps, knives and chemicals/ cleaning supplies were stored beneath the kitchen sink and were secured. The refrigerator/freezer had more than two-days of perishables, fresh fruits and vegetables were observed, and there was seven-days of non-perishable supplies. LPA observed pantry and there were no items that were expired. The kitchen appliances were in working order. The facility temperature was 70 degrees Fahrenheit, was clean and odorless. During the tour LPA observed resident bedrooms which had the required furnishings. Bed rail orders were on file. LPA tested the hot water temperatures in two of two resident bathrooms. The hot water temperature ranged from 113.3 to 113.5 degrees Fahrenheit. Bathrooms had grab bars and non-skid mats and covered trash bins. Carbon monoxide and smoke detectors were inspected and were operational. The fire extinguisher was charged and inspected on March 25, 2025. The last fire drill was conducted on February 3, 2026. A Technical Violation was provided for documentation not in the file. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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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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: A PLACE LIKE HOME 2	FACILITY NUMBER: 306006630
	VISIT DATE: 03/12/2026

NARRATIVE

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(Continued from LIC 809)

LPA toured the exterior of the property and observed a shaded seating area. An Additional Dwelling Unit (ADU) also is on the property lot with a separate address. The ADU is a licensed facility, A Place Like Home 8, RCFE #306006750. There were no hazards or obstruction of pathway and there were two exterior self latching gates. Audible alarms were in working order and are activated at night.

The PUB 475 poster was posted in the hallway with facility theft and loss policy, Emergency Disaster Plan, Client rosters and visiting hours. LPA provided AD with fees payment information which AD will pay. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA observed the First Aid Kit and the facility has a First Aid Manual.

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on December 14, 2027.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Khatera Bahadory, Administrator Designee and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC809 (FAS) - (06/04)

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