374604819-9-30-2025-08-AS-DNGN-DM226H-20250930170710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604819
Report Date: 09/30/2025
Date Signed: 09/30/2025 05:07:44 PM

Document Has Been Signed on 09/30/2025 05:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	NEW WORLD VILLA NORTH		FACILITY NUMBER:	374604819
ADMINISTRATOR/ DIRECTOR:	CHEN, ZAYDEN		FACILITY TYPE:	740
ADDRESS:	15042 AMSO ST		TELEPHONE:	(858) 842-4608
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 6		CENSUS: 0	DATE:	09/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Licensee/Administrator Zayden Chen		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee/Administrator Zayden Chen. According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be non-ambulatory and one may be bedridden. Per LPA observation and manager interview: During today’s inspection, there were a total of zero (0) residents in care. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. LPA, accompanied by the Licensee/Administrator, toured the interior and exterior of the facility, and inspected all common areas and bedrooms. LPA also reviewed the Licensee/Administrator’s personnel file. During the facility tour, LPA observed, and Licensee interview confirmed: -The facility did not have working telephone, as required. -The facility’s fire extinguisher had not been serviced within the last twelve (12) months, as required. [During today’s visit, Licensee phoned a professional vendor to make a service appointment for the extinguisher.] -The facility required cleaning and/or repair in these areas: a) The facility’s doorbell annunciator/speaker was partially dismantled and was not working; b) The facility’s electric garage door (which is a potential emergency exit route per the facility sketch) was not working; c) An electrical outlet in Bedroom #4 was missing a receptacle; d) Two (2) of the electrical outlets in Bedroom #2 were missing plastic covers; [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA NORTH	FACILITY NUMBER: 374604819
	VISIT DATE: 09/30/2025

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[CONTINUED FROM LIC 809] e) A window screen in Bedroom #2 was broken; f) The sliding window screen in the Living Room was broken; g) Two (2) of the drawers in Bathroom #1 were missing pull knobs; h) Stowed inside Bedroom #6 was a non-working refrigerator/freezer combo that Licensee said was junk and needed to be discarded.

-Hot water temperature at taps intendend for resident use were too hot, per regulation: Bathroom #1 Sink was 131.4 F and Bathroom #2 Sink was 139.3 F. [Regulation required these taps to be between 105 F and 120 F.]

-1 of 2 bathroom showers did not have a slip-resistant mat, strip, or similar flooring, as required.

-The facility had Internet service but did not have a telecommunications device at the facility which was dedicated for resident use.

Pathways were free of obstruction and trip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 76 F. Appliances to preserve perishable food were also compliant in temperature. Cooking/dining equipment and utensils were present and in good condition. There was a locked area for the storage of client medication. Confidential records were stored in locked areas. The facility’s fireplace was screened, as required. The facility did not have a swimming pool or similar body of water. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, night lights, and emergency lighting were working. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance.

Since the facility currently has zero (0) clients in care, no deficiencies were cited during today’s inspection. However, LPA issued six (6) Technical Violations (refer to the LIC 9102-TV pages).

An exit interview was conducted with Licensee/Administrator Zayden Chen, to whom a copy of this report, the LIC9102-TV pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC809 (FAS) - (06/04)

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