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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005785
Report Date: 08/27/2026
Date Signed: 08/27/2026 01:52:45 PM

Document Has Been Signed on 08/27/2026 01:52 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:B & C ELDERLY CAREFACILITY NUMBER:
306005785
ADMINISTRATOR/
DIRECTOR:		ESTORBA, BRIAN A.FACILITY TYPE:
740
ADDRESS:9342 LIME CIRCLETELEPHONE:
(714) 488-8413
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 6DATE:
08/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Jilmark RealisTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


The facility is a single level structure and licensed for six residents and six residents are admitted to the facility. There’s a total of 5 bedrooms (4 resident and 1 staff room) and 2 restrooms available. There’s a living room space, a dining space, backyard area and an attached garage. Bedrooms: All bedrooms have the required furnishings. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in between 105.8 – 106.1 degrees F. Kitchen: 4 of 4 burners and the warmer were operational on the gas stove. Sharps are stored in the locked medication cabinet near the refrigerator. Food Service: A food supply that meets regulation requirements was observed.
Client & Staff Files: Resident and staff files are located in locked cabinet in the garage.
File Review: Five resident files and three staff files were reviewed during the inspection.

Medications/First-Aid Kit: Resident medications are stored in a locked kitchen cabinet near the refrigerator. A first aid kit with all the required elements was observed in the medication cabinet.



Medication Review: All six resident medication were reviewed during the visit.

Continued on LIC809C
Kevin Saborit-Guasch
Jerome Haley
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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 10
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 08/27/2026 01:52 PM - It Cannot Be Edited


Created By: Jerome Haley On 08/27/2026 at 12:45 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: B & C ELDERLY CARE
FACILITY NUMBER: 306005785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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. During a review of Resident 1's (R1) medication, Duloxetine HCL DR 30MG was being administered and was not listed on the medication administration record which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Assistant Administrator Jilmark Realis stated he would review and ensure all medications are on the residents medication list and add the missing medication to the medication administration record (MAR). An updated medication list and MAR will be emailed to LPA Haley by 4:00pm on the POC due date.
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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. During a review of Resident 2's (R2) medication, two different PRN's for R2 (Acetaminophen ER 650 MG & Loperamide 2 MG) were administered, but not documented on the R2's medication administration record (MAR) which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Assistant Administrator Jilmark Realis stated he would schedule an In-service training on medication administration for staff who administer medications. Administrator Jilmark will email LPA Haley a sing in sheet and a breakdown of the in-service medication training (Topics covered & Duration of the training) and/or a certificate of completion for all staff who completed the medication training by 4:00pm on the POC 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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2026 01:52 PM - It Cannot Be Edited


Created By: Jerome Haley On 08/27/2026 at 12:45 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: B & C ELDERLY CARE
FACILITY NUMBER: 306005785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 confirmation, the licensee did not comply with the section cited above which poses a potential safety risk to persons in care.
POC Due Date: 09/02/2026
Plan of Correction
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Assistant Administrator Jilmark Realis stated he will conduct a evacuation drill by the POC due date and provide LPA Haley information on the evacuation drill that was completed and a list of participants in the drill.
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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
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: B & C ELDERLY CARE
FACILITY NUMBER: 306005785
VISIT DATE: 08/27/2026
NARRATIVE
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Linens & Hygiene Supplies: Hygiene items were observed in locked cabinets in the main hallway. Additional hygiene and incontinent care supplies were observed in the garage.

Garage Area: Walk ways were free of obstruction. A laundry area equipped with a washer and dryer was observed. A office area was observed. An additional perishable and nonperishable food supply was observed. Emergency items were observed including a supply of emergency food and water.

Backyard/Exterior: A table and chairs was observed under a shaded gazebo areas. There’s a storage shed in the back yard with miscellaneous facility items.

Bodies of Water: None
Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers was observed mounted on the wall in the kitchen and on mounted on the wall in the living room area.

An emergency evacuation drill: Have not been conducted.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:


Facility postings are posted are available for review on the wall near the front door.
Additional Comments: Contact information was reviewed and updated during the visit.

Deficiencies are being cited as a result of today’s inspection, and Technical Advisories will be issued.

An exit interview conducted, and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
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