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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001212
Report Date: 09/12/2025
Date Signed: 09/12/2025 03:20:43 PM

Document Has Been Signed on 09/12/2025 03:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HCDD - DIANAFACILITY NUMBER:
306001212
ADMINISTRATOR/
DIRECTOR:		BOYD BRADSHAWFACILITY TYPE:
735
ADDRESS:2732 E. DIANA AVENUETELEPHONE:
(714) 666-8661
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 4DATE:
09/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Kim Southern - AdminstratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On September 12, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using CARE Tools. Upon arrival at the facility, LPA Bentley was greeted and granted entry into the facility by staff after stating the purpose for the visit. The Administrator (AD) Kim Southern was contacted by telephone, arrived a short time after, and remained throughout the visit. The facility is a single-level structure licensed for six (6) ambulatory clients, age 18 through 59 and offers Adult Residential Care.

LPA Bentley conducted a tour of the physical plant accompanied by AD Southern and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the client's personal belongings were observed in clients’ closets and drawers. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured at 105.4 degrees F and 110.1 degrees F. Smoke and carbon monoxide detectors were tested and operational.



All client bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in cabinets. All appliances are operational during today's visit. Medication is stored in a locked cabinet in the kitchen. There is a washer and dryer in an area near the kitchen and both were found to be in working condition. Knives and sharp objects were unlocked in a drawer under the stove. Hazardous cleaning chemicals were found unlocked in a cabinet, under the sink. Additional sharps and toxins were observed unsecured in Bathroom #1. A deficiency is being cited.

REPORT CONTINUES TO LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HCDD - DIANA
FACILITY NUMBER: 306001212
VISIT DATE: 09/12/2025
NARRATIVE
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The garage was clean organized, and walkways were free of clutter and debris. A refrigerator with a supply of perishable and non-perishable items was observed. The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs observed. Facility has emergency food and water supply.


LPA Bentley observed a first aid kit with all the required elements. Two fully charged fire extinguishers were observed mounted with a last service date of June 19, 2025. The facility’s last fire drill was conducted on September 1, 2025. A working telephone (714-666-8661) remains available. Facility has liability insurance on file effective April 28, 2025 through April 28, 2026.

A review of four (4) clients service files and four (4) staff personnel files were complete. LPA conducted an audit of client P&I records. A review of the Medication and Medication Administration Record (MAR) was also conducted. LPA observed three medications without prescription labels, two of which the facility did not have prescription orders for and one that was found unsecured in Bathroom #1 cabinet. A deficiency is being cited.


Based on observations, deficiencies are being cited during today’s inspection visit, per Title 22, Div. 6, Chapter 6 of the California Code of Regulations.

An exit interview was conducted with Administrator (AD) Kim Southern and a copy of the report, LIC809-D, and appeal rights were provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2025 03:20 PM - It Cannot Be Edited


Created By: Eboni Bentley On 09/12/2025 at 02:49 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HCDD - DIANA
FACILITY NUMBER: 306001212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate risk to clients in care. In kitchen, LPA observed toxins in cabinet and sharps in a drawer with non-operational locks and accessible to clients in care. Sharps were also observed accessible in a drawer in Bathroom #1, accessible to clients in care.
POC Due Date: 09/13/2025
Plan of Correction
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During the inspection, the staff secured these items and LPA confirmed. Administrator stated they will train staff on securing
dangerous items and submit proof to LPA/CCLD via email by 9/13/2025.
Type A
Section Cited
CCR
80075(b)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate risk to clients in care. LPA observed three medications without prescription labels, two of which the facility did not have prescription orders for and one that was found unsecured in Bathroom #1 cabinet.
POC Due Date: 09/13/2025
Plan of Correction
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During the inspection, the staff secured medication and LPA confirmed. Administrator stated they will train staff on properly securing medications, obtaining physican's orders, and ensuring medications have prescription labels intact. Proof will be submitted to LPA/CCLD via email by 9/13/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/12/2025 03:20 PM - It Cannot Be Edited


Created By: Eboni Bentley On 09/12/2025 at 02:54 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HCDD - DIANA
FACILITY NUMBER: 306001212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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