197606738-10-7-2025-31-AS-ERIS-DM8R9M-20251007124946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606738
Report Date: 10/07/2025
Date Signed: 10/07/2025 12:50:25 PM

Document Has Been Signed on 10/07/2025 12:50 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AQUAMARINE RETIREMENT HOME		FACILITY NUMBER:	197606738
ADMINISTRATOR/ DIRECTOR:	MARICAR MEDINA		FACILITY TYPE:	740
ADDRESS:	6523 W. AVENUE L-7		TELEPHONE:	(661) 418-0715
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	10/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Glennard Tiu - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Evelin Rios arrived at the facility above to conduct an annual required visit. LPA was granted access by Staff #1 (S1) and asked to sign in and check temperature. LPA met with the administrator, Glennard Tiu. LPA explained the reason for the visit. LPA observed appropriative postings through out the facility. At 9:55 a.m., LPA conducted a tour of the physical plant of the facility inside and out and the following was observed: Common Areas: The facility has converted the previous sitting room into two (02) rooms, a bedroom and office/storage room. The living room has a television with enough seating to accommodate the capacity of the facility. There is a fire place that was adequately screened. The dining area has a table and chairs observed in good repair. Areas were observed clean and clear of clutter. The facility maintains a comfortable temperature at 72°F. The carbon monoxide detector was observed on a wall by the living room, functioning. Kitchen: The kitchen was observed clean with sufficient supply of two-day perishables and seven-day non-perishables foods. LPA observed the knives and sharp objects locked in a kitchen drawer. The facility has sufficient amount of dining ware and cook ware in good repair. There are two (02) fire extinguishers, one (01) by the kitchen and the other by the bedrooms observed fully charged with service date 06/20/2025. At 10:08 a.m., the administrator tested smoke detectors located throughout the facility. LPA observed smoke detectors to be functioning properly. (Continued to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
	VISIT DATE: 10/07/2025

NARRATIVE

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Bathrooms: LPA toured two (02) designated resident bathrooms. One (1) bathroom is located in a shared bedroom for private use. Both bathrooms were observed with non-skid matts, grab bars, toilet paper, paper towels and hand soap. The hot water was tested at 12:29 p.m., from one (01) of two (02) bathrooms and measured 112.1 degrees Fahrenheit, within regulation.

Bedrooms: LPA toured five (5) resident bedrooms. LPA observed rooms to have appropriate bedding and lighting. There is a night stand and sufficient storage. Auditory alarms on exit doors were on and observed operational. Administrator will submit documentation to clear a 6th bedroom for resident use. Bedroom is currently vacant.

Laundry/Garage: The laundry room is accessible to residents. LPA observed chemicals/hazardous items in a locked cabinet in the laundry room inaccessible to residents in care. The laundry room leads to the attached garage that is used to store extra food in a freezer and for facility storage.

Outside: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with an umbrella offering a shaded area for residents. No bodies of water on the premises.

Resident and Staff Files: At approximately 10:50 a.m., LPA reviewed resident and staff files. LPA conducted a file review of five (05) out of five (05) resident records and four (04) staff records to ensure compliance of licensing forms. LPA reviewed facility's Emergency Disaster Plan and Training, annual training and Certificate of Liability Insurance.

Medications: At approximately 12:01 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a kitchen cabinet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). LPA also observed a complete first aid kit with manual.

There were no deficiencies observed during today's visit. Exit interview conducted. Copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC809 (FAS) - (06/04)

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