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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005835
Report Date: 08/20/2026
Date Signed: 08/21/2026 12:37:43 PM

Document Has Been Signed on 08/21/2026 12:37 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:KIRKWOOD ORANGEFACILITY NUMBER:
306005835
ADMINISTRATOR/
DIRECTOR:		ZEHRA SYEDFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVENUETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 66CENSUS: 48DATE:
08/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:ED ErinTIME VISIT/
INSPECTION COMPLETED:
12:01 PM
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On August 21, 2026, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced required one-year annual inspection. LPA Haddadin introduced himself, explained the purpose of the visit, and was granted entry into the facility by ED Erin Palposi

The facility is licensed to serve 66 non-ambulatory residents, of whom eight may be bedridden, and has an approved hospice waiver for 15 residents. At the time of the inspection, three residents receiving hospice services were in care.

The facility is a two-story building consisting of 58 private and shared resident rooms. Assisted Living and Memory Care units are located on both floors. Common areas include activity rooms, a bistro, an ice cream parlor, a salon, dining rooms on both levels, and enclosed outdoor patios equipped with delayed-egress gates.

LPA Haddadin conducted a tour of the interior and exterior areas of the. No bodies of water or safety hazards were observed on the premises. Resident rooms were inspected and found to be appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space was available for residents’ personal belongings. The hot water temperatures measured in resident bathrooms and kitchen sinks ranged from 112.8 to 117.3 degrees Fahrenheit.

The facility was observed to be clean, sanitary, and appropriately furnished. Toxic substances, cleaning supplies, and sharp objects were securely stored and inaccessible to residents.

Alisa Ortiz
Samer Haddadin
DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2026
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: KIRKWOOD ORANGE
FACILITY NUMBER: 306005835
VISIT DATE: 08/20/2026
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The kitchen was inspected and contained an adequate food supply consisting of at least two days of perishables and seven days of nonperishables. Emergency food and water supplies were also available.

LPA Haddadin observed eight fully charged and properly mounted fire extinguishers. Three evacuation chairs were available near the second-floor stairwells. The facility’s smoke and carbon monoxide detectors were tested on August 21, 2026, and were operational. The facility’s most recent fire drill was conducted on June 22, 2026. The first-aid kit was complete and maintained, and a working landline telephone was available.

LPA Haddadin reviewed six Medication Administration Records (MARs), and all six records were complete and in compliance. LPA Haddadin also reviewed four resident records and four staff records. All records reviewed were complete and up to date. Based on observations made during today’s inspection, no deficiencies are being cited pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Executive Director Dan Kashani, and a copy of this report was provided at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC809 (FAS) - (06/04)
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