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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006705
Report Date: 10/24/2025
Date Signed: 10/24/2025 11:53:38 AM

Document Has Been Signed on 10/24/2025 11:53 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: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:
10/24/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:mTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On October 24, 2025, Licensing Program Analyst (LPA) Eboni Bentley and Licensing Program Manager (LPM) Lourdes Montoya conducted an announced subsequent Pre-Licensing continuation visit. LPA and LPM were allowed entry and met with Applicant Moe Jerrar. The purpose of today's visit was to follow-up on the issues that were present during the initial Pre-Licensing visit on October 9, 2025.

During the today's visit, the following issues below have been corrected:
· Clear passageways in the garage. Store water hoses on respective racks.
· Install grab bars in resident bathrooms
· Ensure that the home/residents' 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 emergency water supplies
· Ensure ADU is occupied by facility staff only and person(s) are associated with facility
· Missing postings- Ombudsman poster, Visitor hours and policy, and Food menu.
· Submit proof of liability insurance policy.

CONTINUE TO LIC809-C.....
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2025
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 3
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: 10/24/2025
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During today's inspection, following the items reviewed during the visit are not in compliance:
· 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
· Missing postings- Admission agreement.
· 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)
· Provide an umbrella for outdoor covered seating area
· Repair leaking sprinkler system for landscape
· Remove dead and dry brush and debris around exterior of physical plant
· Clean outdoor pool/body of water
· Remove rack over toilet in resident bathroom
· Repair, remove, level stone hazard in the backyard walkway
· Repair doorbell to remove loud sound

Due to the below pending issues, pre-licensing cannot be approved at this time.

Based on today’s observation, the facility is not ready for licensure. A subsequent visit will be conducted to review the corrections on November 4, 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: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC809 (FAS) - (06/04)
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