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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001215
Report Date: 10/03/2025
Date Signed: 10/03/2025 10:48:18 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/03/2025 10:48 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELIZABETH HOMES/SAN RICARDOFACILITY NUMBER:
306001215
ADMINISTRATOR/
DIRECTOR:		SANTOS, ELIZABETHFACILITY TYPE:
735
ADDRESS:6303 SAN RICARDO WAYTELEPHONE:
(714) 828-6140
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
10/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Maxine KniazeffTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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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 six ambulatory clients. As of today, the facility has four clients admitted to the facility. All four clients were present at the beginning the visit, and three of them left for their day program after the visit started. There’s a total of 6 bedrooms, of which 4 bedrooms are for the clients, one bedroom has been converted into activity area and one bedroom is vacant and empty. There are two restrooms available. There’s a living room space, a dining space, and activity area and an attached garage/storage area. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. No chemicals observed in the bathroom. Hot water was measured in the range of 105.8 - 107 degrees F. Kitchen: 4 of 4 burners are operational on the gas stove. Sharps are kept locked in a cabinet below the counter next to the chemicals stored in the locked cabinet directly under the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen, and the pantry area above the washer and dryer in the laundry area.

Client & Staff Files: Client and staff files stored in the main office.
File Review: 3 of 4 client files were reviewed during the visit, and 3 staff files were reviewed.


Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELIZABETH HOMES/SAN RICARDO
FACILITY NUMBER: 306001215
VISIT DATE: 10/03/2025
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Medications/First-Aid Kit: Client medications are stored in a locked medication cabinet in the activity area. One first aid kit was observed in the locked cabinet with emergency supplies, food, and water near the dining room. Another first aid kit was observed in the main hallway closet.
Medication Review: 3 of 4 client medications were reviewed during the visit.

Linens & Hygiene Supplies: Hygiene items and hygiene caddy’s were observed in a locked closed in the main hallway.

Garage/Storage Room: The garage is clean, organized and has been converted into a storage room. A refrigerator with and additional perishable food supply and clothing items were observed.

Backyard/Exterior: The backyard is clean and organized. Walkways are free of obstruction. A table with some chairs was observed under a shaded patio area. A basketball court and a ping pong table was observed. Bodies of Water: None

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers were observed mounted on a wall in the kitchen and on the wall next to bedroom #5.

An emergency evacuation drill: Was conducted September 5, 2025. Evacuation drills are conducted monthly. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Several facility postings are posted and available for review on the main postings board in the activity room.

Additional Comments: Licensing fees are current. During the visit, 3 of 4 client files were reviewed, 3 of 4 client P&I funds were counted, and medications were reviewed for 3 of 4 clients. 3 staff files were reviewed during the visit, and 2 staff were interviewed. Facility contact information was reviewed and updated during the visit.



No deficiencies are being cited during today’s visit.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC809 (FAS) - (06/04)
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