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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006815
Report Date: 12/11/2025
Date Signed: 12/11/2025 11:13:50 AM

Document Has Been Signed on 12/11/2025 11:13 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:A PLACE LIKE HOME VIIFACILITY NUMBER:
306006815
ADMINISTRATOR/
DIRECTOR:		BEN, SHEILA MARIEFACILITY TYPE:
740
ADDRESS:13551 TAHOE STREETTELEPHONE:
(909) 894-6454
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 6CENSUS: 0DATE:
12/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Robert Barcelona and Sheila BenTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Licensee (LE) Robert Barcelona and Administrator (AD) Sheila Ben.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by our agency on August 1, 2025, for a total capacity of six residents, three maybe non-ambulatory, and one maybe bedridden in Bedroom #5. The fire clearance was approved by a fire inspector from the Orange County Fire Authority on August 28, 2025.

The facility is a one-story home with six resident bedrooms, four bathrooms, living room, kitchen, and dining area and detached garage. There are two exit gates on both sides of the house that are self-latching and unlocked. There is a shaded seating area for clients in the backyard. LPA did not observe any obstacles or hazards. There are activities such as games and puzzles for residents to play and participate in.

LPA observed Administrator certificate, Facility sketch and Emergency Disaster Plan in the facility mounted on the wall in the dining area. The See Something, Say Something poster (PUB 475), Long Term Care Ombudsman poster, and Personal Rights were posted up on the walls of the dining area as well.

Resident bedrooms had the required furnishings. Bedrooms with doors to the backyard and outside had working door alarms. LPA observed all beds had linens and blankets. There is an ample supply of linens and towels. Smoke detectors and carbon monoxide detectors tested operational. Hot water temperatures in the bathrooms measured around 109.2 Fahrenheit degrees.

Bathrooms were observed to be operational and have a working toilet, wash basin, and bathtub/shower, as well as grab bars and non-skid surface mats. Toxins are secured and locked underneath the kitchen sink and garage.

(Pre-licensing Report continuation on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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: A PLACE LIKE HOME VII
FACILITY NUMBER: 306006815
VISIT DATE: 12/11/2025
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Medications will be stored in a locked cabinet in the hallway by the kitchen. The first aid kit with all the required elements and first aid guidebook was observed in the medication cabinet as well. Records will also be stored alongside medication in the locked cabinet. A phone is in the dining room for residents to use. The facility also has a laptop for residents to use and keep in touch with family.

A supply of perishable and non-perishable food was observed. Electric stove burners, refrigerator, dishwasher, microwave, washer, and dryer are operational. Sharps are stored in a container, locked and secured in a cabinet in the kitchen. Emergency food and water and additional supplies were observed to be well stocked in the hallway. The fire extinguisher by the front door is fully charged.

The facility is ready to be licensed. LPA conducted the Component Three Orientation with Licensee Robert Barcelona and Administrator Sheila Ben. Facility was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Licensee and Administrator.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

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

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