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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006774
Report Date: 11/12/2025
Date Signed: 11/12/2025 05:02:11 PM

Document Has Been Signed on 11/12/2025 05:02 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:AUGUSTINE HOMES IIFACILITY NUMBER:
306006774
ADMINISTRATOR/
DIRECTOR:		AU, AUGUSTINEFACILITY TYPE:
740
ADDRESS:8455 NEPTUNE DRIVETELEPHONE:
(626) 631-6485
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 0DATE:
11/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Augustine AuTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by Applicant Augustine Au

Initial application: To operate a Residential Care Facility for the Elderly (RCFE), with a capacity of four (ambulatory only) residents, was submitted to the department for licensure. However, the facility needs to be licensed for four non-ambulatory residents.



Fire clearance: Orange County Fire Authority granted the Fire Clearance August 21, 2025

Structure:
The facility is a one-level structure, with an attached garage. There’s a total of 6 bedrooms (4 for residents, and 2 activity rooms) and 2 bathrooms for the residents in care. There’s a living room space, a dining space, backyard, and attached garage. Bedrooms: all bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Non-skid matts were observed. Hot water was measured in the range or 109.4 – 111.5 degrees F. Kitchen: 4 of 4 burners and the warmer are operational on the stove. Sharps are kept locked in a drawer near the stove. Chemicals are kept locked below the kitchen sink. Food Service: A supply of perishable and non-perishable food items was observed.

Garage Area: The garage is clean and organized. A washer and dryer was observed. Chemicals are stored in a locked cabinet. Incontinent care supplies are stored in the garage, and additional hygiene supply of hygiene item are stored in the garage. A washer and dryer and an exercise bike was observed. Walkways are free of obstruction.
Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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: AUGUSTINE HOMES II
FACILITY NUMBER: 306006774
VISIT DATE: 11/12/2025
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Toxins: All toxic chemicals, soaps, detergents, and cleaning solutions are inaccessible to residents and locked under the sink in the kitchen and locked in a cabinet in the garage area.

Resident & Staff Files: Files are stored in the main office and in the locked closet next to the front door.

Medications/First-Aid Kit: Resident medications are stored in the locked closet next to the front door.
Linens & Hygiene Supplies: Hygiene items were observed in the bathroom. Additional hygiene items were observed in the garage. Additional linens were observed.

Backyard/Exterior: The backyard is clean and organized. A shaded patio area with a table and chairs was observed. Two locked storage sheds were observed. Both storage sheds are empty.
Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguisher was observed mounted on the wall in the kitchen.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:
There’s a postings board with emergency phone numbers, personal rights, and other postings in the main hallway area.

Additional Comments: Facility contact information was reviewed and updated during the visit.

Component III: was not presented at this time.

The applicant needs to be licensed for three non-ambulatory residents. The current fire clearance was granted for 4 ambulatory clients only. The facility is not ready to be licensed at this time.

An exit interview was conducted, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
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