<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004332
Report Date: 09/02/2025
Date Signed: 09/02/2025 04:52:20 PM

Document Has Been Signed on 09/02/2025 04:52 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:CANDLEWOOD MANORFACILITY NUMBER:
306004332
ADMINISTRATOR/
DIRECTOR:		NORAJOY KINNEYFACILITY TYPE:
740
ADDRESS:15781 CANDLEWOOD STREETTELEPHONE:
(714) 531-4522
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 5CENSUS: 3DATE:
09/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Irish TacsuanTIME VISIT/
INSPECTION COMPLETED:
05:00 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) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. The House Manager (HM) Irish Tacsuan arrived shortly to assist with the visit. The facility is licensed for five non-ambulatory residents of which one may be bedridden with a hospice waiver for four. Currently there are three residents, of which one is on hospice during today's visit.

LPA Tea reviewed three resident files and four staff files. Staff files contained all required documentation. There are some discrepancies with resident files. Upon review of records, the facility is up to date with required quarterly emergency disaster drills, which were last conducted in July 29, 2025. The administrator certificate expires May 31, 2025.

LPA Tea along with staff toured the facility. LPA toured the physical plant, checked the food service, and the first aid kit. The facility is a two-story home, the first floor consists of 3 resident bedrooms, 2 bathrooms, a living room, dining room, kitchen and attached garage. The second floor is only for staff where live in care staff resides, no residents reside on the second floor. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational, they are maintained and serviced through a third-party security company. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. The water temperature measured around 106.5 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free (Annual continuation on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2025
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 6
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)
Page: 2 of 6
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: CANDLEWOOD MANOR
FACILITY NUMBER: 306004332
VISIT DATE: 09/02/2025
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
26
27
28
29
30
31
32
of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at the time of visit. LPA observed sharps locked and inaccessible to residents in a kitchen drawer. LPA also observed toxin substances secured underneath the kitchen sink and in cabinets in the garage.

The fire extinguishers are fully charged throughout the facility. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There are two exit gates that are self-latching and operational on both sides of the house. LPA observed PPE supplies, emergency food and water stored in the garage. Facility provides activities based on resident personal choice and health condition. Residents like to play bingo, dominoes, and other games. Sometimes they go for walks around the neighborhood. At the time of the visit, LPA observed residents lounging in the living room watching television.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the dining area. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility and a copy of this report LIC809, along with the 809-C, LIC858, LIC859, and 9102TV were read and provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6