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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005705
Report Date: 04/08/2026
Date Signed: 04/08/2026 04:59:39 PM

Document Has Been Signed on 04/08/2026 04:59 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:EDWARD BOARD AND CARE HOMEFACILITY NUMBER:
306005705
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:117 EDWARD AVE.TELEPHONE:
(714) 290-3809
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 4DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Direct Support Professional Lissette OsunaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Brandon Lopez and Nancy Guillen made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry into the facility by care giving staff after explaining the purpose for the today's visit. Administrator Marisa Hernandez was notified via telephone but could not arrive to assist with the inspection. LPAs observed that Marisa Hernandez has a current administrator's certificate with an expiration date of March 31, 2027.

The facility is an Adult Residential Facility (ARF) licensed for four ambulatory clients. The facility is a single story home with four private client bedrooms, one staff bedroom, three shared client bathrooms, a den, a living room, a dining room, and a kitchen. LPAs accompanied by a care giving staff conducted a tour of the interior portion of the facility. On today's visit, LPAs observed one client present and one care staff present. Per staff, two of the clients were with family and friends and one of them was at work. LPAs inspected the four private client bedrooms and observed them to be free of hazards. LPAs observed the client bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPAs observed client beds to have clean linens and blankets. LPAs observed additional linens to be stored in a hallway closet. LPAs tested the individual smoke detectors in each of the client bedrooms which tested operational. LPAs inspected the three client bathrooms and observed them to be clean. Faucets and toilets were operational. Hot water temperature measured 126.3 degrees and 128.3 degrees Fahrenheit.

LPAs observed the kitchen has a two day perishable and a seven day nonperishable food supply on hand. LPAs observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. LPAs observed kitchen knives and sharps to be stored in a locked cabinet in the den. LPAs observed fire extinguishers to be mounted on the wall in the kitchen and in the client hallway. CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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 4
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: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705
VISIT DATE: 04/08/2026
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Fire extinguishers were observed to be charged and up to date on service. LPAs tested the individual carbon monoxide detectors which tested operational. LPAs observed the emergency disaster drill has not been conducted in the last two quarters. The last drill was conducted on August 26, 2025.

LPAs observed the centrally stored medication to be kept in a locked storage cabinet located in the den. LPAs observed a First Aid Kit to be stored in a closet in the den and it had all the required components. LPAs observed chemicals and toxins to be stored in a locked container in the closet. LPAs observed the facility has a three day emergency food and water supply located in the den.

LPAs, accompanied by a staff, conducted a tour of the exterior portion of the facility and observed it to be free of hazards. LPAs observed a shaded outdoor area for client use. LPAs observed the facility has outdoor furniture for client use. LPAs observed the perimeter gates on the north side and south side of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPAs reviewed all four client files. All required components were present in the files reviewed. LPAs reviewed clients' medication and medication records. LPAs reviewed four staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, deficiencies are being cited on the attached LIC809-D page. An exit interview was conducted with Administrator Marisa Hernandez via telephone. The report was signed by an authorized facility representative. A copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/08/2026 04:59 PM - It Cannot Be Edited


Created By: Brandon Lopez On 04/08/2026 at 04:26 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: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in three out of three bathrooms, which poses a potential health, safety or personal rights risk to persons in care. LPAs observed bathroom water temperatures to range between 126.3 degrees and 128.3 degrees Fahrenheit.
POC Due Date: 04/24/2026
Plan of Correction
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Administrator stated they will adjust the water temperature to fit within the required range. The administrator will create a temperature log to document the water temperature. The administrator agreed to provide the temperature log to LPA via email or fax by POC date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility has not conducted an emergency disaster drill in the last 2 quarters with latest being done on August 26, 2025.
POC Due Date: 04/24/2026
Plan of Correction
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The Administrator stated that she will conduct an emergency disaster drill with all staff. The Administrator agreed to provide LPA proof of the emergency disaster drill via email or fax 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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