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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006705
Report Date: 10/09/2025
Date Signed: 10/09/2025 02:06:28 PM

Document Has Been Signed on 10/09/2025 02:06 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:FOUNTAIN OF YOUTH SENIOR LIVING 2FACILITY NUMBER:
306006705
ADMINISTRATOR/
DIRECTOR:		ABDALLA, SUHAFACILITY TYPE:
740
ADDRESS:525 N HANDY STREETTELEPHONE:
(714) 941-9690
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 6CENSUS: 0DATE:
10/09/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Suha Abdalla - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On October 9, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley arrived announced for the purpose of conducting the Pre-Licensing visit for an Initial Application. LPA conducted the visit with Applicants/LLC Members Suha Abdalla and Moe Jerrar. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on January 28, 2025 for age range 60 and over.

LPA toured the facility's indoor and outdoor physical plant with Applicants Abdalla and Jerrar.

The following were observed:

Structure:
The facility is a single-story property in a residential neighborhood comprised of five resident bedrooms, three full bathroom, and staff/caregiver bedroom located in an ADU in the backyard. There is also a gated pool in the backyard. Currently, the ADU is occupied by a tenant not associated to the facility. All bedrooms inside the main building will be for resident use. LPA observed all common areas which include the living room, dining area, kitchen, and an unattached two car garage.

Telephone Number:
Facility land line number (714) 941-9690 was tested and remains available.

CONTINUE TO LIC809-C ....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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: FOUNTAIN OF YOUTH SENIOR LIVING 2
FACILITY NUMBER: 306006705
VISIT DATE: 10/09/2025
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Emergency Phone Numbers/Exit Plan:
Posted on the bulletin board.

Postings:
The See Something, Say Something (PUB475) was in the correct size and posted at the entry way. Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and Administrator Certificates were also posted. The Ombudsman Poster, Food Menu, a copy of the Admissions Agreement, and Visitor hours and policy were missing.

Food Service and Menu:
A sufficient amount of emergency food was observed. The facility does not have a seven-day supply of non-perishable, two-day perishables, and emergency water available.

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 purchased on February 13, 2025.

Fire Clearance:
Approved on August 11, 2025 for 6 residents of which, 2 are ambulatory, 3 non-ambulatory, and resident may be bedridden.

Signal System:
There is a signal system is connected to exit door alarms throughout the facility.

Reading Material, Games, Equipment, & Materials:
Games and activities will be stored 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: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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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: FOUNTAIN OF YOUTH SENIOR LIVING 2
FACILITY NUMBER: 306006705
VISIT DATE: 10/09/2025
NARRATIVE
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Bedrooms:
Residents’ bedrooms had all required furniture, are spacious, and easily accommodate the residents’ belongings.
Four out of five bedrooms contained hospital beds of which one had a full rail and two had ½ rails installed. Three or more beds were missing the following items: Bedspreads, top sheets, bottom sheets, pillow cases, and mattress pads,
Per Applicant, Resident Bedroom #3 contained personal belongings from applicant’s previous tenant and will be removed and ready for resident use. Personal belongings were observed in closet and drawers.

Bathrooms:
All three bathrooms were operational with slip resistant mats in place. Grab bars were present in one out of three bathrooms. All bathrooms were missing bath towels, wash clothes, and hand towels.

Water Temperature:
The water temperature in three bathrooms measured at 127.2, 128.4, and 131.9 degrees Fahrenheit.

Linens and Hygiene Supplies:
Clean linens were not adequately stocked and no hygiene supplies for resident use were observed.

Appliances:
Stove burners, microwaves, refrigerator, freezer, and washer/dryer were inspected and operating. LPA observed damage to outer covering of microwave and applicant stated intentions to replace the microwave with a new one.

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

Medication:
Medication will be secured in a file cabinet in the kitchen.

CONTINUE TO LIC809-C ....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
Page: 5 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: FOUNTAIN OF YOUTH SENIOR LIVING 2
FACILITY NUMBER: 306006705
VISIT DATE: 10/09/2025
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Sharps and Toxins:
Sharps were observed to be secured and inaccessible. Cleaning supplies and toxins were observed in a locked cabinet under kitchen sink.

First Aid Kit, & Manual:
The First Aid Kit and manual were checked and found to be in order.

Backyard
There are two sheds in the backyard that will be used for storage.

Garage
The garage is being used for storage with a significant amount of clutter and debris. There are no clear walkways.

ADU/Caregiver Room
The caregiver room is currently being rented to a tenant not associated to the facility. Applicant expressed intent to relocate the tenant prior to accepting residents, with the date of move out unknown at this time.

Liability Insurance:
Facility does not currently have liability insurance.


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


CONTINUE TO LIC809-C ....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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: FOUNTAIN OF YOUTH SENIOR LIVING 2
FACILITY NUMBER: 306006705
VISIT DATE: 10/09/2025
NARRATIVE
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The following items require correction:
  • Clear passageways in the garage and yard. Store water hoses on respective racks.
  • Install grab bars in all bathrooms
  • Ensure that the home/resident’s bedroom spaces and garage are de-cluttered and ready for use
  • Regulate water temperatures in all bathrooms to measure between 105 and 120 degrees Fahrenheit.
  • Adequately stock non-perishable food and emergency water supplies
  • Remove hospital bed and rails and replace with bed approved for residents use
  • Deep clean inside and outside of physical plant to ensure facility is sanitary and in good repair
  • Ensure ADU is occupied by facility staff only and person(s) are associated with facility
  • Ensure all emergency supplies which include but are not limited to such as large & small flashlight, propane/gas lanterns with back up propane, small portable stove, whistle/bell, charger, and cooler are obtained per the Emergency Disaster Plan (LIC610E)
  • Amend the LIC610E reflecting the type of residents served (non-ambulatory, bedridden)
  • Missing postings- Ombudsman poster, food menu, visitor hours and policy, 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 on October 23, 2025 and Applicant will contact the department if an extension is needed.

An exit interview was conducted with Applicant Moe Jerrar, 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: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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