306004761-8-26-2026-22-AS-CGUZ-DXBUZY-20260826160218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004761
Report Date: 08/26/2026
Date Signed: 08/26/2026 04:02:34 PM

Document Has Been Signed on 08/26/2026 04:02 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:	CAMBRIDGE COURT		FACILITY NUMBER:	306004761
ADMINISTRATOR/ DIRECTOR:	LAUREN CHON		FACILITY TYPE:	740
ADDRESS:	1621 COMMONWEALTH AVENUE, EAST		TELEPHONE:	(714) 992-1750
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY: 99		CENSUS: 78	DATE:	08/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:51 AM
MET WITH:	Lauren Chon Maria "Lupe" Jaime		TIME VISIT/ INSPECTION COMPLETED:	04:20 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) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Office Assistant Jaritza Carmona and the purpose of the inspection was discussed. Supervisor Lupe Jaime arrived at approximately 10:00 a.m. Administrator (AD) Lauren Chon arrived at approximately 3:00 p.m. During the inspection, LPA and Supervisor conducted a physical tour of the facility. LPA observed select resident bedrooms. Bedrooms were observed to have the required furnishings, with the exception of Resident 1 (R1), who did not have a bed or bed frame. Per Supervisor, R1 prefers to sleep in their recliner and does not want a bed. LPA observed all other residents’ beds had linens and blankets. Residents were observed having lunch, consisting of chow mein, orange chicken, and steamed cabbage. Bathrooms were observed to be free of debris and mildew and faucets and toilets were operational. Water temperature tested between 114.8 – 120.0 degrees Fahrenheit. The facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke detectors and carbon monoxide detectors tested operational. A fire extinguisher was observed in every facility hallway. Fire extinguishers were observed to be fully charged with service tags dated December 9, 2025. Gas stove, microwave, laundry washer and dryer were all observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked. LPA reviewed select resident medication and Medication Administrator Records (MARs) and observed three residents' MARs were incomplete. LPA reviewed eight resident files and three staff files. Three of three staff files did not include required training. LPA interviewed select residents and staff. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

Lourdes Montoya
Claudia Gutierrez
	DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

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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Document Has Been Signed on 08/26/2026 04:02 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 08/26/2026 at 02:47 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: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one of three staff files, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/11/2026
	Plan of Correction
1 2 3 4	AD stated required staff training will be completed a copy provided to LPA via email by POC date.

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:

	Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 08/26/2026 04:02 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 08/26/2026 at 02:47 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: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two of three staff files which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/11/2026
	Plan of Correction
1 2 3 4	AD stated staff training will be completed and a copy provided to LPA via email by POC date.

Type B

Section Cited

CCR

87209(a)(2)

(a) The use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: (2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above as R1's bedroom does not have required furnishings and a written request for exception was not submitted to licensing agency, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/11/2026
	Plan of Correction
1 2 3 4	AD stated a written request for a waiver or exception and substantiating evidence supporting the request will be submitted to LPA via email by POC date.

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:

	Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2026 04:02 PM - It Cannot Be Edited

Created By: Claudia Gutierrez On 08/26/2026 at 03:34 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: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, as three residents' MARs were observed to be incomplete, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/11/2026
	Plan of Correction
1 2 3 4	AD stated MARs will be completed and staff training regarding maintaining accurate MARs for residents will be conducted and a copy provided to LPA via email by POC date.

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:

	Claudia Gutierrez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026

LIC809 (FAS) - (06/04)

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