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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006118
Report Date: 05/21/2026
Date Signed: 05/21/2026 11:21:14 AM

Document Has Been Signed on 05/21/2026 11:21 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:HILLS OF SHAY DEL, THEFACILITY NUMBER:
306006118
ADMINISTRATOR/
DIRECTOR:		NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:5982 SHAY DEL PLACETELEPHONE:
(626) 827-9547
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 4DATE:
05/21/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Caregiver- Yumi LumuthangTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On May 21, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced case management visit for a Health and Safety check. LPA Kim was greeted and granted entry by Caregiver (CG) Yumi Lumuthang. LPA Kim spoke over the telephone with Administrator (ADMIN) Heddy Mae Oyson and explained the purpose of the visit. ADMIN Oyson stated she could not make today's visit and CG Lumuthang could sign on behalf of the facility.

LPA Kim conducted a health and safety check. During the visit, LPA toured the facility and observed the following: LPA observed two staff on duty providing care to four residents. Facility maintained ample 2-day perishables and 7-day non-perishables in the kitchen. Staff stated food gets delivered one time per week. Resident hygiene supplies are stored in their bathrooms and extra supplies in the garage. The hot water temperature measured at 124.8 degrees F and 125.6 degrees F. The indoor temperature measured at 76 degrees F. All smoke detectors and carbon monoxide detectors were operational. All emergency disaster supplies were prepared and available in the garage. Facility land line (714) 646-9615 was tested and remains available. No obstacles observed in the backyard. All staff on LIC 500 are cleared and associated to the facility. Residents interviewed stated satisfaction with facility services and denied any issues with food supply or utilities. LPA conducted interviews with three residents and two staff. LPA observed valid certificate of liability insurance effective April 2, 2026, and expires on April 2, 2027. LPA spoke with residents and resident responsible parties who stated they were not provided written notice that the Department is commencing proceedings to revoke the facility's license

CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
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 5
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118
VISIT DATE: 05/21/2026
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While on tour of the facility, LPA Kim noticed the facility did not post a notice about the Department commencing proceedings to revoke the facility's license. The regulation states the notice needs to be in 14-point type and be posted in a conspicuous location at the facility. During the visit, the facility adjusted the hot water temperature and it was measured between 118.6 degrees F and 120.0 degrees F.

Deficiencies were cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Hot water temperature for resident bathrooms measured between 124.8 degrees F and 125.6 degrees F. The facility adjusted the hot water temperature during the visit and it measured between 118.6 degrees F and 120.0 degrees F. LPA spoke with residents and residents' responsible party who stated they were not notified about the Department commencing proceedings to revoke the facility's license. Facility did not post up a notice about the Department commencing proceedings to revoke the facility's license. The notice needs to follow the regulation of being in 14-point type and posted in a conspicuous location at the facility. A Civil Penalty was assessed during the visit for a repeat violation for resident bathrooms hot water temperature. A previous licensing report of the same violation was issued on February 17, 2026. The facility has been issued the civil penalty due to a repeating the same violation within 12 months.

An exit interview was conducted, and a copy of this report, LIC809D, LIC421IM, and appeal rights were provided to Caregiver Yumi Lumuthang.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/21/2026 11:21 AM - It Cannot Be Edited


Created By: Edward Kim On 05/21/2026 at 08:18 AM
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
HSC
1569.38(b)(1)

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1569.38 (b)(1) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party...within 10 days The department commences proceedings to... revoke the license.
This requirement is not met as evidenced by
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Licensee states they will inform with a written notice to all residents and resident's responsible party the Department is commencing proceedings to revoke the facility's license. Licensee will send a copy of the written notice and proof they provided written notices to the resident and resident's
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Based on interviews and record review, the licensee did not comply with the section cited above. The facility did not provide a written notice to residents and resident's responsible party about Department proceeding to revoke the facility's license. This poses an immediate health, safety or personal rights risk to persons in care.
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responsible party to CCLD via email to edward.kim@dss.ca,gov by POC due date May 22, 2026.
Type A
05/22/2026
Section Cited
HSC1569.38(e)

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1569.38(e) Upon providing the notice... the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility...

This requirement is not met as evidenced by:
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Licensee state they will post the notice and meet all the requirements for HSC 1569.38(e). They will send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date May 22, 2026.
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Based on observation and record review, the licensee did not comply with the section cited above. The facility did not post a notice about the Department commencing proceedings to revoke the facility's license. This poses an immediate health, safety or personal rights risk to persons in care.
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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2026 11:21 AM - It Cannot Be Edited


Created By: Edward Kim On 05/21/2026 at 09:31 AM
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2026
Section Cited
CCR
87303(e)(2)

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87303 (e)(2) ... Faucets used by residents for personal care ... shall deliver hot water. Hot water temperature controls shall be maintained...to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Deficiency cleared during the visit. Facility adjusted the water temperature for resident bathrooms that measured at 118.6 degrees F and 120.0 degrees F
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident bathrooms hot water temperature measured between 124.8 degrees F and 125.6 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
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Civil Penalty assessed for repeat violation.

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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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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