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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005287
Report Date: 06/26/2026
Date Signed: 06/26/2026 11:43:19 AM

Document Has Been Signed on 06/26/2026 11:43 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:AMERIHEART CARE HOMEFACILITY NUMBER:
306005287
ADMINISTRATOR/
DIRECTOR:		YCASAS, TIMOTHYFACILITY TYPE:
740
ADDRESS:9622 KATELLA AVENUETELEPHONE:
(714) 733-8095
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
06/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Roy Santa AnaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced annual required inspection of the facility. LPA was greeted by care staff, who granted entry to the facility. The purpose of the visit was explained. Administrator (AD) Roy Santa Ana arrived shortly after to assist with the inspection. The facility is licensed to care for six non-ambulatory residents and has an approved hospice waiver for two residents. At the time of the visit, the facility had four residents and none were receiving hospice services.

LPA reviewed four resident files and four staff files. The files contained the required documentation. The Administrator's certificate is scheduled to expire on July 5, 2026. AD Santa Ana stated that the required renewal course work will be completed and submitted for renewal.

LPA and AD Santa Ana toured the facility. The single-story home consists of five resident bedrooms, two resident bathrooms, two staff bedrooms, a living room, dining area, kitchen, laundry area, office, attached garage, and backyard. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Resident bedrooms were clean and furnished with required furniture, bedding, and adequate storage space. Resident bathrooms were clean and in good repair. Toilets, sinks, and showers were functioning properly, grab bars were securely installed, and no mold or mildew was observed. Hot water measured between 105.1°F and 106.5°F. Towels, toiletries, and personal hygiene supplies were adequately stocked.

Common areas were clean, orderly, and free of hazards. Hallways and exits were unobstructed. The first aid kit contained all required supplies. Kitchen appliances were operational. Perishable and nonperishable food


(Annual inspection continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
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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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: AMERIHEART CARE HOME
FACILITY NUMBER: 306005287
VISIT DATE: 06/26/2026
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supplies met regulatory requirements. Sharps and toxic substances were observed to be locked and inaccessible to residents. Fire extinguishers were fully charged and properly maintained. The facility's most recent emergency disaster drill was conducted on May 6, 2026. Emergency food and water supplies were available. Outdoor areas were clean, safe, and provided shaded seating for residents. Exit gates on both sides of the property were self-latching and functioning properly.

Medications were stored in a locked closet and administered according to physicians' orders. LPA verified resident personal and incidental (P&I) funds were accurately maintained with no discrepancies. LPA also interviewed residents regarding the quality of care and spoke with staff about services provided. During the visit, residents were observed listening to music and watching television. The administrator reported that residents regularly participate in activities such as bingo, board games, and community outings such as dining at restaurants, shopping, and visits to local parks.

Based on observations, record reviews, and interviews conducted during today's inspection, the facility was in compliance with the areas inspected. No deficiencies were cited under Title 22, Division 6 of the California Code of Regulations.

This report was reviewed with the facility. Copies of the LIC809, LIC809-C, LIC9102, LIC858, and LIC859 were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC809 (FAS) - (06/04)
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