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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006688
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:41:23 PM

Document Has Been Signed on 06/04/2025 03:41 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:ROSSMOOR MANORFACILITY NUMBER:
306006688
ADMINISTRATOR/
DIRECTOR:		BANOS, RICARDOFACILITY TYPE:
740
ADDRESS:2932 CHANNING WAYTELEPHONE:
(562) 572-9931
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 0DATE:
06/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:09 AM
MET WITH:Applicant Ricardo BanosTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a two story residential home. LPA Tirre along with Applicants Ricardo Banos and Flormine Resurreccion toured facility at 8:15AM and observed the following:

Fire clearance approval was received on 2/3/2025 for Six (6) Non Ambulatory residents , one (1) of which can be Bedridden. Fire Clearance is approved for residents residing on first floor. Second floor is not accessible for residents and will be used as live in bedrooms for staff Structure: Facility is a two story, 6 resident private bedrooms located on first floor and two live in staff bedrooms located on second story. Facility Has three (3) full bathrooms with attached two car garage and white exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements and has required furnishings Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface mats in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens, blankets, towels as well as secured hygiene supplies. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall and required postings. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Home has combination Smoke detectors and carbon monoxide detectors which are centrally wired and tested operational. Fire extinguishers are mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all exit doors and perimeter gate.

CONTINUED ON 809C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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: ROSSMOOR MANOR
FACILITY NUMBER: 306006688
VISIT DATE: 06/04/2025
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Appliances: Gas stove, refrigerator and microwave are operational. Toxins: LPA observed cleaning supplies and sharps secured in storage area and closet. Water Temperature: Tested and recorded between 109.2 to 119.1 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has puzzles, games, books and music therapy being provided. Facility has tablet with Internet access available for residents use. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility along with First Aid Manual. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by walls with a self latching gate on both sides of facility as required. Facility has audible alarms on perimeter gates. LPA observed shaded outdoor seating.

Administrator's Certificate for Ricardo Banos observed on wall expiring 1/11/2026.



Component III Orientation was conducted during visit.

No deficiencies noted during todays visit. The pre-licensing visit has been completed.


An exit interview was conducted with Administrator and a copy of report was left at facility

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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