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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005475
Report Date: 05/19/2026
Date Signed: 05/19/2026 04:42:43 PM

Document Has Been Signed on 05/19/2026 04:42 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:FOUNTAIN VALLEY SENIOR HOMES 2FACILITY NUMBER:
306005475
ADMINISTRATOR/
DIRECTOR:		ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:17690 SAN VICENTETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
05/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Uldarico Almiranez (Administrator)TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On today's date Licensing Program Analyst (LPA) William Vanegas conducted an unannounced visit for the purposes of conducting an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by facility staff. LPA explained the purpose of the visit, and Administrator (AD) Uldarico Almiranez was notified via telephone and arrived shortly after to assist LPA with the inspection. LPA began a tour of the facility and observed the following. AD Uldarico Almiranez has a valid Administrator certificate valid from April 11, 2026 through April 10, 2028.
The facility is a one storied home with a total of seven bedrooms six of which are used for residents in care and one of which is used for live in staff. The facility is equipped with three bathrooms two of which are shared, and one of which is used for staff and visitors. The facility is equipped with an attached two car garage, and a large backyard. LPA observed teh kitchen area to be clean and free of any mildew and debris. LPA observed kitchen area to be equipped with an electric stove, a refrigerator, and a microwave. LPA observed a two day supply of perishable food and a seven day supply of non-perishable food on hand. LPA observed a sufficient amount of emergency water on hand for residents in care as well.
LPA observed all resident rooms to be clean and free of any hazards or debris. LPA observed all resident rooms to be large enough to walk about freely, and to have all required furnishings including the following: A reading lamp, a bed, clean linens in good repair; meaning no strains or tears, a chest of drawers, and enough storage space to store personal belongings. LPA observed all restrooms to be clean and free of any mildew and debris. LPA observed restrooms to have all required furnishings including a shower chair, slip resistant floor matts, and grab bars. All toilets and faucets appeared to be in good repair and tested operational. Hot water temperature tested between 109.0 and 109.5 degrees Fahrenheit. CONTINUED ON LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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)
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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: FOUNTAIN VALLEY SENIOR HOMES 2
FACILITY NUMBER: 306005475
VISIT DATE: 05/19/2026
NARRATIVE
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LPA observed all smoke detectors and carbon monoxide detectors to be in good repair, and tested operational. LPA observed all fire extinguishers to be fully charged and have an updated service tag attached to it. LPA observed first aid kit to have all required items including the following: Scissors, tweezers, adhesive tape, bandages, a thermometer, and a first aid manual.

LPA conducted a tour of the outside of the facility and observed the following: The backyard of the facility has an outdoor shaded sitting area, the backyard is large enough to participate in outdoor activities upon resident request. LPA observed the backyard to be free of any hazards, debris, or obstructions blocking exit routes a long the exit routes of the facility. LPA observed side doors to be unlocked and self latching.

LPA reviewed six resident files and three staff files. All resident files had all required documents. However three of three staff files did not have an updated CPR certification and a deficiency was issued on today's date, additionally three of three staff did not have updated annual training and a deficiency was issued on today's date. LPA reviewed medications with AD and all medications appeared to be documented correctly. Per LPA's review all medications are being administered per physicians orders. LPA observed the medication cabinet to be unlocked and a deficiency was issued on today's date.

Based on observations made during today's inspection deficiencies will be issued per title 22 chapter 6 division 8 of the California Code of Regulations. An exit interview was conducted with AD and a copy of this report and appeal rights were provided to the facility. Additionally a copy of this report will be mailed to the facility.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/19/2026 04:42 PM - It Cannot Be Edited


Created By: William Vanegas On 05/19/2026 at 04:22 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: FOUNTAIN VALLEY SENIOR HOMES 2
FACILITY NUMBER: 306005475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three of three staff on duty not having a valid CPR/FIrst aid certification. Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Administrator agrees to assign all staff members to complete CPR/First Aid Certification training. Administrator will submit proof of correction to LPA via email by P.O.C due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 04:42 PM - It Cannot Be Edited


Created By: William Vanegas On 05/19/2026 at 04:22 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: FOUNTAIN VALLEY SENIOR HOMES 2
FACILITY NUMBER: 306005475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three of three staff on duty not having updated annual training which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/09/2026
Plan of Correction
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Administrator agrees to complete all staff training by P.O.C due date. Administrator will send proof of correction to LPA via email by P.O.C due 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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/19/2026 04:42 PM - It Cannot Be Edited


Created By: William Vanegas On 05/19/2026 at 04:22 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: FOUNTAIN VALLEY SENIOR HOMES 2
FACILITY NUMBER: 306005475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 as LPA observed the medicine cabinet to have a faulty lock installed; meaning broken due to staff not having a key for the lock. Which poses potential health risk to persons in care.
POC Due Date: 06/02/2026
Plan of Correction
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Administrator agrees to fix the lock and have a key readly available to all staff on duty. Administrator will provide proof of correction to LPA before P.O.C Due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
William Vanegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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