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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006313
Report Date: 08/13/2026
Date Signed: 08/13/2026 05:02:00 PM

Document Has Been Signed on 08/13/2026 05:02 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 OF YOUTH SENIOR LIVINGFACILITY NUMBER:
306006313
ADMINISTRATOR/
DIRECTOR:		JERRAR, MOE A.FACILITY TYPE:
740
ADDRESS:525 N CAROUSEL PLACETELEPHONE:
(657) 208-3199
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 6DATE:
08/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Moe Jerrar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the House Manager at 12:30pm. LPA met with Moe Jerrar, Administrator (AD) and explained the purpose of the visit.

The facility is a single story, six bedroom, three bathroom residence with an approved fire clearance for six non-ambulatory residents in which one can be bedridden in Room #3. The facility has an approved hospice waiver for six residents. Currently there are six residents in care in which there are no residents receiving hospice services. At time of entry LPA observed two residents having lunch.

During the visit LPA toured the kitchen and observed the facility had two days of perishable items and seven days of non perishable items on hand. LPA observed food pantry items were not expired and there was plenty of fresh fruit and vegetables. A knives drawer was not locked and a deficiency will be given. Chemicals and cleaning supplies were secured underneath the kitchen sink. Kitchen appliances were in working order and clean.

LPA tested the carbon monoxide and smoke detectors and both detectors were operational. The fire extinguisher was charged and inspected on April 29, 2026. The facility's last fire drill was conducted on November 25, 2025. A fire drill will be scheduled with care staff for Sunday, August 16, 2026. LPA measured the hot water temperatures in three of three resident bathrooms. The hot water temperatures ranged between 105.6 to 116.6 degrees Fahrenheit.

(Continued on LIC 809-C)
Alisa Ortiz
RoseMarie Ruppert
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
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: FOUNTAIN OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313
VISIT DATE: 08/13/2026
NARRATIVE
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(Continued from LIC 809)

LPA toured the exterior of the property and observed a shaded seating area and the live-in staff lives in the permitted Additional Dwelling Unit (ADU). A landscaper was outdoors clearing foliage and there is ample space for outdoor activities. The outside gates are open and have latches. Video cameras oversee the perimeter of the property and do not include audio.

LPA observed the medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid Kit is on site but Administrator ordered an additional First Aid Kitwith a book. LPA observed the See Something, Say Something (PUB 475) and Long Term Care Ombudsman posters posted along with Personal Rights, Theft and Loss and Client Rosters posted in prominent areas.

LPA reviewed two of two staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has an administrator certificate which expired on July 21, 2026 but AD has submitted all continuing education units and is on the pending renewal list. LPA reminded AD that the licensing fees are due on August 29, 2026.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Moe Jerrar, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC9102-TV and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/13/2026 05:02 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 08/13/2026 at 04:19 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and interview the licensee did not comply with the section cited above in six of six residents which poses an immediate health and safety or personal risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
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AD will send LPA pictures via email or text of repaired sharps drawer by POC 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/13/2026 05:02 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 08/13/2026 at 04:19 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observations and file review, the licensee did not comply with the section cited above in three of three resident files which poses a personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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AD will obtain signed admissions agreements for three of three resident files by POC due date and will email agreements to LPA.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and file review, the licensee did not comply with the section cited above in three of three resident files which poses a personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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AD will provide re-appraisals and Appraisal Needs and Services Plans to LPA via email by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/13/2026 05:02 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 08/13/2026 at 04:19 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's file review and interviews, the licensee did not comply with the section cited above in two of six residents which poses a potential health and safety risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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AD will obtain Medical Assessments for two of six residents by POC due date. AD will email LPA documentation.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's file review and interviews, the licensee did not comply with the section cited above in two of six residents which poses a potential health and safety risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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AD will conduct re-appraisals for two of six residentsi in care. AD will email LPA by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/13/2026 05:02 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 08/13/2026 at 04:19 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 OF YOUTH SENIOR LIVING
FACILITY NUMBER: 306006313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

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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2
3
4
Based on LPA interview and record review the licensee did not comply with the section cited above in six of six residents which poses a potential health and safety risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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AD will provide quarterly fire drill with all staff and will email LPA documentation by POC due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations and file review, the licensee did not comply with the section cited above in three of six residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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2
3
4
AD will obtain bed rail orders for three of six resident and will email LPA orders by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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