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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006756
Report Date: 09/15/2025
Date Signed: 09/15/2025 10:57:04 AM

Document Has Been Signed on 09/15/2025 10:57 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:TRIHAVEN ASSISTED LIVINGFACILITY NUMBER:
306006756
ADMINISTRATOR/
DIRECTOR:		MARTIROSIAN, HRACHIAFACILITY TYPE:
740
ADDRESS:3650 RANDEE WAYTELEPHONE:
(714) 425-0445
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 0DATE:
09/15/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Amr Danial and Administrator Hrachia MartirosianTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On September 15, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an announced visit to the facility to conduct the pre licensing inspection. LPAs were greeted and granted entry into the facility by Licensee Amr Danial (LI) and Administrator (AD) Hrachia Martirosian. LPAs observed that Hrachia Martirosian has a valid Administrator certificate which expires on August 10, 2027.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of six, of which five can be non-ambulatory residents and one can be bedridden was received by Community Care Licensing (CCL) on April 1, 2025. This is an initial application with no residents in care. The facility received an approved Fire Clearance by the Fullerton Fire Department Inspector Peggy Castaneda on May 16, 2025.

The facility is a single story home with five resident bedrooms, one of which are shared, two shared resident bathrooms, a living room, a dining room, a kitchen, a laundry room, and an attached two car garage. On today's visit, LPAs accompanied by the LI and the AD, conducted a tour of the interior portions of the facility. LPAs observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPAs inspected the five resident bedrooms and observed them to be free of hazards. LPAs observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed resident beds to have clean mattresses, linens, and blankets. LPAs observed additional linens to be stored in each residents bedroom. LPAs inspected the two shared resident bathrooms and observed them to be free of hazards. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 116.6 and 116.7 degrees Fahrenheit.

LPAs observed kitchen appliances such as the refrigerator, the dishwasher, and the microwave to be clean and operational. LPAs observed the five burner gas stove lights unassisted. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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: TRIHAVEN ASSISTED LIVING
FACILITY NUMBER: 306006756
VISIT DATE: 09/15/2025
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LPAs observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPAs observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPAs observed staff and resident files will be kept in a locked cabinet in the kitchen. LPAs observed a First Aid Kit to be stored in the kitchen and it has all the required components. LPAs observed the facility has a three day emergency food and water supply stored in the kitchen. LPAs observed a fire extinguisher mounted on the wall in the kitchen and it was observed to be charged and purchased on September 11, 2025. LPAs tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPAs observed a fire place in the living room and it was observed to have a screen and not be in operation at time of visit. LPAs observed activity materials such as cards, board games, and books stored in the living room. LPAs observed medications will be kept in a locked closet in the resident hallway. LPAs observed the attached two car garage to be kept locked. LPA observed the two car garage to be used for storage.

LPAs, accompanied by the LI and the AD, conducted a tour of the exterior portion of the facility. LPAs observed the exterior to be free of any obstructions or hazards. LPA observed a shaded outdoor seating area with furniture for resident use. LPAs observed a shed located in the backyard which was empty and will be used for storage. The perimeter gates of the facility are self-latching can be opened in an evacuation. There are no bodies of water on the premises.

Component III was completed with the LI and the AD, which provided information about how to operate the facility within compliance and reporting requirements. The LI and the AD were notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted with Licensee Amr Danial and Administrator Hrachia Martirosian and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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