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Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a health and safety check on the three residents in care. LPA met with Administrator/ Licensee Carolyne Rico LPA Tirre checked in on residents who were relaxing in their bedrooms. Residents appeared comfortable in appearance. LPA made the following observations during visit: Gas was operable as evidence by gas stove working Electricity operable as evidence by lights and central air working Water operable and tested and measured at 109 F TV/ Phone/ Internet operable as evidence by LPA calling phone number Two fridges, freezers and pantry's filled with adequate amount of perishable and non-perishable foods LPA discussed with Licensee Rico that Department needs the past six months of bank statements, Grocery Receipts and utility invoices. LPA discussed with Licensee that Statements and invoices need to be provided by close of business day Wednesday September 9, 2026. LPA discussed with Licensee Rico that department will be scheduling a Non-Compliance Conference (NCC) Meeting and will schedule a future date where Licensee is required to attend in person. LPA Tirre will follow up on date of meeting. Licensee mentioned that they were still searching for an additional Administrator to hire and informed LPA they would provide updates. Licensee also stated that they will be making upcoming payments for Water scheduled on 9/29/2026 and Rent payments on 9/5/2026 and 9/15/2026. An exit interview conducted with Licensee and report provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a health and safety check on the three residents in care. LPA Tirre spoke to each of the residents (R1, R2, R3) and inquired about medications and meals. All three residents stated that their needs are being met by staff at facility. All three residents were observed sitting in living room watching television. LPA also observed the following: Facility has two day perishables and seven day non perishable foods electricity working gas working Water working and operating at 113.1 to 114.6 degrees Fahrenheit Two staff members were currently working phone/cable/internet working Staff 2 stated that all three residents just had nurses that had visited R1-had Home health and Physical Therapy assist with resident today R2-had home health check in R3- had Physical therapy check up LPA observed that facility still does not have a backup designated Administrator acting while Administrator/ Licensee Carolyne Rico is out of country. Based on observation the following is being cited per Title 22 Regulations. A exit interview conducted with staff and copy of report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 28, 2026

87405(a) Administrator Qualifications:(a) All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate for management and administration of the facility This requirement is not being met as evidence of Licensee has not had a designated Admin since 7/22/26 inside facility. This poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: POC: Licensee to hire a designated Administrator to meet requirements of facility. Licensee to hire, associate and have fingerprinted to facility by POC Due date. Send proof to LPA by 8/28/26

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an visit to conduct a case management visit. LPA met with staff and explained the reason for the visit. LPA observed the See Something, Say Something poster (PUB 475) is posted in the living room of the facility and visible from the front door. LPA observed the facility has electricity, gas and water. Facility has hot water. Hot water measured 127.0 degrees Fahrenheit in bathroom #1. LPA observed bathroom #1 is clean and all the plumbing fixtures are operational. LPA observed the kitchen is clean. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the 4 burner gas stove lights unassisted. The knives are kept locked in a kitchen cabinet. The room temperature in the dining room measured 76.4 degrees Fahrenheit. LPA attempted to call the facility phone number, 657-298-3008, but it is no longer in service. LPA observed the medicaiton is kept locked in a tool cart in the dining room. LPA verified the medications are kept locked. During the visit LPA observed the residents were served lunch. During the visit there were 2 staff members at the facility. LPA interviewed 3 residents. All 3 residents reported they were doing well and had no issues. No obstacles or hazards observed inside of the facility. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Aug 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Aug 28, 2026

All facilities shall have telephone service on the premises. This requirement is not being met as evidenced by, LPA attempted to call the facility phone number but the number is no longer in use. This poses a potential, health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2026

Plan of correction: Facility Administrator must ensure the facility has phone service at all times and have the phone service re-connected by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: Aug 21, 2026

Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not being met as evidenced by, The hot water measured 127.0 degrees Fahrenheit in bathroom #1. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2026

Plan of correction: Facility Administrator must adjust the hot water temperature to measure between 105.0 to 120.0 degrees Fahrenheit by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a Health and Safety Check on facility residents in care. During visit LPA met with Caregiver Dulce Madero and explained purpose of visit. During visit LPA Tirre observed the following: Checked facility water which facility had both cold & warm water Electricity operating Gas stove was operable at 6:32 a delivery for groceries arrived and LPA observed 9 bags of groceries which contained fresh produce, juices, milk and bread products LPA attempted calling mainline phone which was still not connected During visit LPA observed one Resident (R1) was asleep and two other residents (R2 &R3) were relaxing in living room watching TV. R2 & R3 stated that their needs were being met today. An exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Aug 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Structure: The facility is a single level structure and licensed for five non-ambulatory residents, one of which may be bedridden. As of today, the facility has four residents admitted to the facility. All four residents were present during the visit. There’s a total of 3 bedrooms and two bathrooms. There’s a living room space, a dining space and an 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, shower, and grab bars. Hot water measured in between 106.1 – 118 degrees F. Kitchen: 4 of 4 burners were operational on the gas stove. Sharps are kept locked in a cabinet below the sink. Chemicals are locked in the cabinet next to the sharps directly below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. Client & Staff Files: Resident and staff files stored in the living room area, in locked cabinets. File Review: 3 of 4 resident files were reviewed during the visit, and three staff files were reviewed. Medications/First-Aid Kit: Resident medications are stored in a locked medication cabinet that is stored in the dining room area. Medication Review: 3 of 4 resident medications were reviewed during the visit. Continued on LIC809C Linens & Hygiene Supplies: Additional hygiene items were observed in a cabinet in the garage. Garage Area: The garage is clean and well organized. The walkways were free of obstruction. A washer and dryer was observed. A cabinet with an emergency food supply was observed. An additional supply of hygiene items was observed. Backyard/Exterior: A shaded area with tables and chairs was observed. An ADU is currently being constructed and is expected to be completed in the next two months. Licensee/Administrator emailed LPA the building permit for the construction. In addition to the ADU, there is an additional space with a room and full bathroom for staff that remains locked and inaccessible to the resident in care. Two storage barn like structures were observed which are used to store miscellaneous facility items. Both storage areas remain locked and are inaccessible to residents in care. Bodies of Water: None. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher was observed mounted on a wall in the kitchen. An emergency evacuation drill: Has not been conducted since 2024. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Several facility postings are posted are available for review on the main postings board in the dining room. Additional Comments: Licensing fees are current. During the visit, 3 of 4 resident files were reviewed, and medications were reviewed for 3 of 4 residents. 3 staff files were reviewed during the visit. Deficiencies are being cited as a result of today’s visit. An exit interview conducted, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 16, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Administrator (AD) Carolyne Rico and the purpose of the inspection was discussed. LPA is following up regarding deficiency previously cited on August 25, 2025 for substantiated findings regarding complaint #22-AS-20250114153838. Deficiency 87468.2(a)(8) was cited due to AD withdrawing a total of $47,741 from July 28, 2024 to January 2, 2025 from Resident 1’s (R1’s) bank account without authorization. AD refunded overcharges to R1’s bank account totaling $39,940, however, remaining overcharge balance of $7,801 was not refunded to R1. During today’s visit, AD wrote a check to R1 in the amount of $7,801 and provided the check to R1 in LPA’s presence. R1 and AD both signed a statement indicating payment in the amount of $7,801.00 in the form of check had been provided to R1. LPA obtained a picture copy of the signed statement dated September 3, 2025. Deficiency previously cited will be cleared. Based on today’s observations, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025

Allegation investigated: Staff financially abused resident

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Administrator (AD) Carolyne Rico and explained the purpose of the inspection. During the course of the investigation the following was revealed: Per Admission Agreement, Resident 1 (R1) was admitted to the facility on July 17, 2024, and is self-responsible. The monthly rate for the basic services was listed as $2,400 with rent payment being due the 1st day of each month. A one-time pre-admission fee of $1,000 was assessed and was due upon admission. During their interview, R1 stated they did not know about a pre-admission fee but paid $1,000 security deposit for damages such as furniture damage. Per R1’s Physician Report dated on July 17, 2024, R1 is non-ambulatory but able to manage their own cash resources. On January 3, 2025, R1 reviewed their financial records and discovered numerous withdrawals had been made by Administrator (AD) Carolyne Rico from their checking account from July 28, 2024 to January 2, 2025, totaling $63,302. (Cont. LIC9099-C) Substantiated On February 28, 2025, the Department subpoenaed Wescom Credit Union and received R1’s financial records. The bank statements were reviewed for the period from July 2024 to January 2025. The total amount of withdrawals made by AD were compared to the total amount of rent that should have been charged. A variance of $47,741 was noted. The total amount of withdrawals by AD was $63,302 and a total amount of $15,561 should been charged for rent, resulting in overcharges totaling $47,741. Each month’s withdrawals made by AD were compared to the monthly rent rate as follows: On July 17, 2024 – R1 admitted to the facility. The prorated rent for July 2024 should have been $1,161 for 15 days and AD withdrew $2,264 from R1’s checking account via PayPal resulting in $1,103 overcharges. In August 2024 – AD withdrew three times from R1’s checking account via PayPal totaling $3,808, resulting in $1,408 in overcharges, as rent for the month should have been $2,400. In September 2024 - AD withdrew five times from R1’s checking account via PayPal totaling $5,687, resulting in $3,287 in overcharges, as rent for the month should have been $2,400. In October 2024 - AD withdrew eight times from R1’s checking account via PayPal totaling $8,219 resulting in $5,819 in overcharges, as rent for the month should have been $2,400. In November 2024 - AD withdrew eleven times from R1’s checking account via PayPal totaling $14,481, resulting in $12,081 in overcharges, as rent for the month should have been $2,400. In December 2024 - AD withdrew twelve times from R1’s checking account via PayPal totaling $20,815, resulting in $18,415 in overcharges, as rent for the month should have been $2,400. In January 2025 – AD withdrew three times from R1’s checking account via PayPal totaling $8,027, resulting in $5,627 in overcharges, as rent for the month should have been $2,400. After R1 reported money shortage in their bank account, AD refunded overcharges to R1’s bank account totaling $39,940, however, remaining overcharge balance of $7,801 was not refunded to R1. (Cont. LIC9099-C) Based on the R1’s financial records, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D), and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 22-AS-20250114153838

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 26, 2025

(a)... residents in... residential care facilities... shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation... This requirement is not met as evidenced by: Based on audit of R1’s financial records, Licensee did not comply with the section cited above as AD withdrew a total of $47,741 from July 28, 2024 to January 2, 2025 from R1’s bank account without authorization, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: AD stated they will restore remaining overcharge balance of $7,801 to R1 and provide the proof to the LPA by POC date.

Allegation investigated: Resident was unlawfully evicted

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Staff Mae Barlahan. Interviews were conducted Licensee, Witness 1 (W1), Resident (R1), and Staff 1 (S1). It is alleged R1 is being unlawfully evicted. During their interview, S1 stated they were not aware of R1 being evicted but stated they received a text message from W1 indicating W1 was making arrangements for R1 to be picked up on today’s date, however S1 stated they were unsure of where R1 was being transferred to. During their interview, Licensee and Witness 1 (W1) denied R1 has been served with any type of eviction notice verbal, written, or otherwise and stated R1 had expressed their desire for physical therapy, and they were searching for placement to accommodate R1’s needs. Licensee and W1 stated placement has not been found and there are no plans to continue to seek placement as R1 has expressed they do not want to leave the facility. During their interview, R1 denied being served with any type of eviction notice, verbal, written, or otherwise. Per R1, they would like to receive physical therapy but within the facility. (LIC 9099-C) Unfounded The Department has investigated the complaint alleging Resident was unlawfully evicted. After interviews conducted with facility staff, witness, and R1, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 22-AS-20250204113631

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20250204113631. LPA met with Staff Mae Barlahan and explained the purpose of the inspection. During the course of the investigation, deficiencies were observed. During interviews, LPA was informed by Individual Felina “Lina” Austria and Administrator (AD) Carolyne “Carol” Rico, one of four residents was hospitalized on January 27, 2024 and continues to be hospitalized. Upon records review, LPA did not observe a written report was submitted to Community Care Licensing (CCL) within seven days of the occurrence; a Deficiency was cited on today’s date. During interviews, Individual Austria stated they were filling in as AD while AD Rico is on vacation out of the country. During their interview, AD Rico confirmed Individual Austria had been filling in for her since December 8, 2024, when she left for vacation. LPA reviewed a list of Guardian roster for facility and was unable to locate clearance for individual Felina Austria and Individual Felorini Brian, who was also presently working at the facility; a Deficiency was cited on today’s date. Based on observations made during this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalty is also being assessed. See the attached LIC421BG. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 5, 2025

(e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Based on observation and AD interview, the licensee did not comply with the section cited above in two of three individuals presently working at the facility, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: AD stated a criminal record clearance or criminal record exemption will be obtained for both individuals and proof provided to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87211(a)(1) · Plan of correction due date: Feb 11, 2025

(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as reporting requirements are not being met, which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Staff Barlahan stated a written report will be submitted to CCL regarding incident and provide LPA with a written plan of action to ensure compliance with regulation via email by POC date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted by Carolyne Rico, Administrator and Ma Julia Chan, Licensee. An application to operate a Residential Care Facility for the Elderly (RCFE) for (5) capacity, (0) ambulatory, (4) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 8/4/2023. Structure: The facility is a one-story home with three client bedrooms, two bathrooms, living room, kitchen, dining room, detached staff lounge, an attached two car garage and backyard. There is a door to the garage from a client room (bedroom 3). This door will only be used to enter the garage in emergencies. To protect the privacy, safety and personal rights of the resident that will reside in bedroom 3, this door will remain locked and the facility staff will use the outside entrance to the garage. There is a back yard with one exit gate on the side of the house. There are three stand-alone structures in the backyard. Two are sheds that will be used for storage. There is also a detached staff lounge with bathroom. Both storage sheds and staff lounge will remain locked to prevent resident access. There are two shaded seating areas on the covered patio in the backyard. LPA did not observe any obstacles or hazards in the backyard. Client Bedrooms: All client bedrooms have the required furnishings. LPA observed all resident beds have linens and blankets. LPA observed all windows were screened. Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 120 degrees Fahrenheit in the bathroom accessible from the hallway and 119.8 degrees Fahrenheit in the bathroom accessible through bedroom 3. LPA advised staff to monitor temperatures. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and are stored and locked in cabinets in the kitchen and garage. Linens & Hygiene Supplies: A supply of extra linen and hygiene are stored in a closet in the hallway and garage. Medication, First Aid Kit and Files: Medication will be locked in cabinet in dining area. First Aid Kit is in a cabinet in the garage and files will be stored in a cabinet in the living room. Activity Materials: The facility has board games stored in the living room. Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 8/30/2023. Smoke/CO2 Detectors & Fire Extinguisher: Dual smoke/CO2 detectors were tested and observed to be operational and connected. LPA observed the fire extinguisher to be fully charged with receipt indicating it was purchased on 8/29/2023. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review Food Service: There is a 7-day supply of non-perishable food on hand. Component III: Presentation was reviewed and provided to the applicant. Information about operating the facility in compliance was reviewed. Appliances: Gas five burner stove/oven, refrigerator, dish washer, microwave, washer, and dryer are operational. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Nov 22, 2023

Type of visit: Office

COMP II by CAB successfully completed Capacity: 5 Census (if any clients in care): Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 27, 2023