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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803389
Report Date: 07/01/2026
Date Signed: 07/01/2026 11:06:32 AM

Document Has Been Signed on 07/01/2026 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ORANGE COMMUNITY CAREFACILITY NUMBER:
197803389
ADMINISTRATOR/
DIRECTOR:		SAAFIR, AHMEDFACILITY TYPE:
735
ADDRESS:2103 ORANGE AVENUETELEPHONE:
(562) 599-0856
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 36CENSUS: 25DATE:
07/01/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Assistant Administrator - Nathaniel StockardTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 07/01/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed on 05/07/2026 during a complaint investigation visit control number 11-AS-20260501095056. LPA met with the Assistant Administrator, Nathaniel Stockard, and the purpose of the visit was explained. LPA was granted entry to the facility.

Technical Advisory is being provided regarding the following:

The facility did not work collaboratively with Client 1’s (C1) medical provider/staff regarding medication administration. C1’s medical provider indicated that their staff went to the facility and requested C1’s Medication Administration Record (MAR) and the facility staff did not provide said records.

Deficiencies observed on 05/22/2026 were as follows:



· The facility did not have a complete medical assessment prior to C1 being admitted to the facility. Admission Agreement states that C1 original admission date was 03/03/2026. C1 did not have a complete Physician’s Report (medical assessment); the document was blank and did not have a physician’s signature.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2026
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
VISIT DATE: 07/01/2026
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· The facility did not store medication in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medication. C1 and Staff 3 (S3) both indicated that C1 provided S3 with a bag of medications at the beginning of April 2026. Observations of C1’s phone confirmed that C1 received a text message on 04/03/2026 indicating that their medication had arrived and the medication was for Vitamin-D2 to be taken once a week for a total of 3 months, which had a quantity of 12 capsules. C1’s medical provider indicated that it is very dangerous to take large dosages of Vitamin-D2 in a short period of time. S3 indicated they placed the bag of medications on a table in the medication office area (the medication office is a shared space with the kitchen and there is no door between the kitchen area and medication office, thus, kitchen staff have access to the medication office). Staff 1 (S1) and Staff 2 (S2) indicated that they did not document medications that were provided to S3 and are not sure what happened to said medications. Witness 2 (W2) confirmed that on 04/03/2026, C1 received a bag that included seven (7) medications which included vitamin D. Records reviewed did not demonstrate that the facility received C1’s medication on 04/03/2026.

· The facility did not follow reporting requirements. According to the document College Medical Center dated 04/30/2026, C1 went to the Emergency Department for an urgent problem due to possible Vitamin-D2 overdose; there were no Unusual Incident/Injury Reports (UIR) submitted to the department regarding said incident.

Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Assistant Administrator, Nathaniel Stockard.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/01/2026 11:06 AM - It Cannot Be Edited


Created By: Socorro Leandro On 07/01/2026 at 09:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2026
Section Cited
CCR
80069(b)(1)

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Client Medical Assessment (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

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The Assistant Administrator has agreed to create a plan to ensure that clients have a complete medical assessment prior to admission. Email plan to Socorro.Leandro@dss.ca.gov.
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Based on record review, the licensee did not comply with the section cited above in not having a complete medical assessment for C1 prior to admission, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
07/20/2026
Section Cited
CCR80075(k)(1)

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Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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The Assistant Administrator has agreed to re-train staff on how to store medications and document medications provided to the facility and email proof of correction to Socorro.Leandro@dss.ca.gov.
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Based on interviews and records, the licensee did not comply with the section cited above in not securing C1’s medication on 04/03/2026, S3 confirmed that they did not store C1’s medication in a locked storage area where kitchen had access to C1’s medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2026 11:06 AM - It Cannot Be Edited


Created By: Socorro Leandro On 07/01/2026 at 10:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2026
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
(1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

This requirement is not met as evidenced by:
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The Assistant Administrator has agreed to re-train staff on reporting requirements and email proof of correction to Socorro.Leandro@dss.ca.gov.
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Based on record review and interviews, the licensee did not comply with the section cited above in not submitting an Unusual Incident/Injury Report (UIR) to the department for C1 when C1 went to the Emergency Department on 04/30/2026 for possible overdose (poisoning) of Vitamin-D2 medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2026


LIC809 (FAS) - (06/04)
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