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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525920299
Report Date: 11/18/2025
Date Signed: 11/18/2025 01:16:57 PM

Document Has Been Signed on 11/18/2025 01:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALOHA HOUSEFACILITY NUMBER:
525920299
ADMINISTRATOR/
DIRECTOR:		NGUYEN, MAI THIFACILITY TYPE:
740
ADDRESS:13765 LISA WAYTELEPHONE:
(530) 529-1052
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 6CENSUS: 4DATE:
11/18/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Mai Thi Ngyuen licensee / administratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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11/18/2025 10:00 AM Licensing Program Analysts (LPAs) Rebecca Knight and Marisa Chiarelli arrived at the facility to conduct a Pre-Licensing visit for a change of ownership (CHOW) with residents in care. LPAs met with licensee / administrator Mai Thi Nyguen and explained the purpose of the visit.

LPAs completed Comp 3 presentation during the visit.

The fire marshal has approved the fire safety inspection request. The facility is licensed for a total capacity of 6 non-ambulatory residents.

The inside of the facility was observed to be in good condition and repair. The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining area, living room,office, covered porch, and front and back yards. LPAs observed 1 dining table with ample seating for residents in the dining room. LPAs observed a couch, chairs and recliner in the living room.

The hot water registered at 111 F degrees which met the Title 22 requirement within a range of 105 - 120 degrees F.

The kitchen was observed to be clean and in good repair. Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and working.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ALOHA HOUSE
FACILITY NUMBER: 525920299
VISIT DATE: 11/18/2025
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The facility has three fully charged fire extinguishers. LPAs observed smoke alarms and carbon monoxide detectors fully functioning.

Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. Each bedroom has ample storage. The facility has multiple linen closets which contain sheets, pillowcases, towels and face cloths. Bathrooms were observed to be in good repair. Storage and lighting are adequate in the home.



Medications are stored in a locking cabinet. Medications were reviewed.

Cleaning supplies and toxins are locked up in a cabinet. Knives are secured. Washer and dryer observed in place and functioning.

There is a locking office space where client and staff files are stored.

There is a covered / screened in porch with a table and seating for the residents to use.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

No deficiencies according to CCR Title 22, Division 6. Exit Interview and copy of report was provided to the licensee.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Rebecca Knight
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC809 (FAS) - (06/04)
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