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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006380
Report Date: 03/18/2026
Date Signed: 03/18/2026 02:00:18 PM

Document Has Been Signed on 03/18/2026 02:00 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:HPNB RESIDENTIAL CAREFACILITY NUMBER:
306006380
ADMINISTRATOR/
DIRECTOR:		ANISH GOREFACILITY TYPE:
735
ADDRESS:709 S PLYMOUTH PL.TELEPHONE:
(714) 866-9108
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 4CENSUS: 1DATE:
03/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Rex LumbosTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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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:


Residential home with two levels and licensed for four ambulatory clients. Three clients are currently admitted to the facility. One client was present before leaving for a doctor’s appointment. The other two clients were at their day program during the visit. There’s a total of 4 bedrooms and 2 bathrooms for the clients. There’s a living room space, a dining space, backyard area, and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. No chemicals observed in the bathroom. Hot water temperature measured in the range of 111.7 – 114.3 degrees F. Kitchen: 4 of 4 burners and the warmer are operational on the gas stove. Sharps are kept locked in a cabinet across from the stove. No cleaning chemicals are stored in the kitchen. All cleaning supplies are stored in a locked closet area near the front door. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen and pantry closet near the entrance. Emergency food, water, and disaster bags were also observed in the pantry closet area near the front door.

Client & Staff Files: Client and staff files stored in a locked closet in the main hallway.
File Review: 3 of 3 client files were reviewed during the visit, and three staff files were reviewed.


Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2026
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: HPNB RESIDENTIAL CARE
FACILITY NUMBER: 306006380
VISIT DATE: 03/18/2026
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Medications/First-Aid Kit: Client medications are triple locked and stored in a closet in the main hallway. A first aid kit with all the required elements was observed in a cabinet under the television in the living room.
Medication Review: 3 of 3 client medications were reviewed during the visit. No discrepancies were noted. Medication is being administered as prescribed.

Linens & Hygiene Supplies: Personal hygiene caddy’s and additional linens was observed in each client bedroom. Additional hygiene items were observed in a locked hallway cabinet.

Garage/Storage Room: The garage is clean, well organized and has walkways free of obstruction. A laundry area was observed with a washer and dryer. An additional refrigerator with an additional perishable food supply was observed. Disaster supplies and additional water were observed in the garage.

Backyard/Exterior: The backyard is clean and organized. Walkways are free of obstruction. A table equipped with a sunshade and chairs was observed.
Bodies of Water: None

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers were observed mounted behind the dining table.

An emergency evacuation drill: An evacuation drill was conducted March 6, 2026. Evacuation drills are conducted monthly. Emergency Phone Numbers, House Rules, Exit Plan & Menu:

Several facility postings are posted and available for review on the postings board near the entrance of the facility.



Additional Comments: Licensing fees are current. Updated facility contact information (mobile number and email address) was provided and the profile will be updated. During the visit 3 of 3 client P&I funds were counted and no discrepancies were noted.

No deficiencies are being cited during today’s visit.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC809 (FAS) - (06/04)
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