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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006685
Report Date: 08/07/2025
Date Signed: 08/07/2025 11:14:45 AM

Document Has Been Signed on 08/07/2025 11:14 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:BEVERLY RESIDENTIAL CAREFACILITY NUMBER:
306006685
ADMINISTRATOR/
DIRECTOR:		DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:9771 BEVERLY LANETELEPHONE:
(714) 300-4540
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 0DATE:
08/07/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Kevin DinhTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Administrator (AD) Kevin Dinh.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by our agency on January 2, 2025, for a total capacity of five non-ambulatory residents and one bedridden resident. The fire clearance was approved by a fire inspector from the Orange County Fire Authority on March 10, 2025.

The facility is a one-story home with three resident bedrooms that will be shared, one staff room, three bathrooms, a living room, a kitchen with a breakfast nook, a dining area, and a detached car garage. There is one entry gate to the property that is unlocked and slides open.

Resident bedrooms had the required furnishings. LPA observed bedrooms with sliding doors had working door alarms. All beds had the required linens and blankets. Hot water temperatures in the bathrooms measured around 106.7 to 109.4 Fahrenheit degrees. Bathrooms were observed to be operational and have a working toilet, wash basin, and bathtub/shower, as well as grab bars and non-skid surface/mat.

A supply of perishable and non-perishable food was observed. Toxins were secured and locked underneath the kitchen sink and in a storage closet in the laundry area. Sharps are secured in a drawer. Gas stove burners, dishwasher, refrigerator, microwave are operational. There is a laptop in the kitchen for the residents to use as well as an iPads provided to residents for activities and productivity. AD Dinh said the residents will be playing games and activities on the laptop and iPad. His residents at the other facilities play games and do activities electronically on the iPads. He will also have musical therapy. A phone is in the kitchen for residents to use. LPA observed Administrator certificate, Facility sketch and Emergency Disaster

(Pre-licensing Report continuation on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BEVERLY RESIDENTIAL CARE
FACILITY NUMBER: 306006685
VISIT DATE: 08/07/2025
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Plan and required posters in the facility mounted on the wall in the kitchen.

In the backyard there is plenty of shaded seating area for residents and LPA did not observe any obstacles or hazards. Emergency food and water and additional supplies were observed to be well stocked in the garage. The fire extinguisher in the kitchen is fully charged. Smoke detectors and carbon monoxide detectors tested operational.

Medications will be stored in a locked cabinet by the kitchen area. The first aid kit with all the required elements and first aid guidebook was observed in the medication cabinet as well. Records will also be stored alongside medication in the locked cabinet.

The facility is ready to be licensed. LPA conducted the Component Three Orientation with Administrator Kevin Dinh. Facility was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC809 (FAS) - (06/04)
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