Humble Heart Home

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. The facility is licensed for four non-ambulatory residents of which one may be bedridden and has a hospice waiver for three. The facility is a 3 bedroom and 1 bathroom home. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in resident bathroom. The hot water temperature measured at 111.2 Fahrenheit and all smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed Resident 2 (R2) had half rails without a physician's order. The facility has not conducted any emergency drills. LPA observed a rollaway bed in bedroom 2 , per staff it is used for staff sleep in the living room. LPA observed a large tub of laundry detergent unsecured in facility kitchen. LPA observed unsecured medications in small refrigerator near the kitchen table. LPA observed unsecured sharps in facility kitchen. LPA reviewed five out of six staff fingerprint records. LPA did not observe current staff training records. Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were not associated to the facility and have worked multiple days. LPA conducted a complete review of resident records. Resident records contained all the required documentation. LPA confirmed that administrator has a current administrator certificate which expires October 10, 2027. Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report and appeal rights were provided to facility representative.the state’s words, verbatim · CDSS document, Jul 21, 2026

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for the purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on November 8, 2024. LPA met with designated Administrator (AD) Lady Yvette Lee. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on July 12, 2024. At 8:00 a.m. LPA toured the facility and observed the following: New facility sketch is consistent with floor plan. New fire clearance was approved by a fire inspector of the Anaheim Fire Department on July 17, 2025. New fire clearance approved for (4) capacity, (0) ambulatory, (3) non-ambulatory, and (1) bedridden residents. Special conditions noted, “Bedridden will be placed in 'back bedroom' labeled on DVAC map. No staff and residents allowed in the garage and shall be used for storage only.” The facility is ready to be licensed. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Lady Lee. An application to operate an Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on July 12, 2024. Structure: The facility is a one-story house with three resident bedrooms, one bathroom, a living room, a kitchen, a dining area, and unattached two car garage consisting of one staff office and one bathroom. LPA observed the See Something, Say Something poster (PUB 475) in the facility posted on the wall in the entranceway. There is a backyard with an exit gate on one side of the house and one exit gate located behind the unattached garage. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry area. Resident & Staff Files: Records will be kept in a locked file cabinet. Medications, First-Aid Kit & Book: Medication will be in a locked cabinet. First aid kit is stored with the medication and has all the required elements. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire extinguisher is fully charged. Reading Material, Games, Equipment & Materials: The facility has reading books, activity books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the living room. Fire clearance: Was approved by a fire inspector of Anaheim Fire Department on September 26, 2024. Special conditions noted, “Bedridden in ‘back’ bedroom.” Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There is no staff bedroom. Bathrooms: Bathroom has working plumbing. Hot water measured at 113.5 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu was posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. Licensee to address the following corrections by November 22, 2024: · New facility sketch consistent with floor plan to be submitted to Centralized Applications Bureau (CAB). Updated facility sketch must identify staff office and bathroom located in the garage. LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Nov 8, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: LADY YVETTE LEE Interview Method: Telephone interview On October 08, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 8, 2024