306006387-3-11-2026-22-AS-HGOH-DS3VZX-20260311165327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006387
Report Date: 03/11/2026
Date Signed: 03/11/2026 04:53:58 PM

Document Has Been Signed on 03/11/2026 04:53 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:	ANAHEIM VILLA		FACILITY NUMBER:	306006387
ADMINISTRATOR/ DIRECTOR:	WINE, LEA		FACILITY TYPE:	740
ADDRESS:	3411 W BALL ROAD		TELEPHONE:	(714) 821-9660
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 210		CENSUS: 113	DATE:	03/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Lea Wine		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrators (AD) Lea Wine and Christine Chon and discussed the purpose of the visit.

The facility is a three story building with resident rooms on each floor, a memory care unit on the first floor, dining rooms, kitchen, laundry rooms, activity rooms, staff offices and outdoor seating areas. The facility appears clean, safe and sanitary. LPA observed all resident rooms to have the required components and furnishings. LPA observed the resident bathrooms to have paper towels, toilet paper and textured shower flooring. LPA tested the water in resident rooms on all three floors to be between 111.7-117.8 degrees Fahrenheit. LPA observed the kitchen to be clean and free of vermin. LPA observed the walk-in fridge and freezer to be at regulatory temperatures to maintain food quality. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the kitchen to have a lock when not in use making the knives inaccessible to residents in care. LPA and AD tested the delayed egress in the memory care unit and it was found to be operational. LPA and AD tested the signal system and had a 2 minute response while in the memory care unit as well as the assisted living side of the facility. LPA observed the memory care dining room to be free of any sharps. LPA observed the toxins and chemicals to be locked in a closet in the kitchen as well as a housekeeping closet on the 3^rd floor and made inaccessible to residents in care. LPA observed a clean supply of linens in the laundry room on the 2^nd floor for resident use. LPA observed the centrally stored medication to be in the wellness office located on the first floor locked in cabinets and medication carts and made inaccessible to residents in care. LPA observed a completed first aid kit in the medication room with all the required components.

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

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: ANAHEIM VILLA	FACILITY NUMBER: 306006387
	VISIT DATE: 03/11/2026

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LPA observed fire extinguishers throughout the facility charged and with a service date of February 13, 2026. LPA observed an outdoor shaded seating area in the memory care unit as well as the assisted living side of the facility that is free of obstructions and debris.

LPA reviewed staff files and 1 of 5 staff do not have updated annual training. LPA reviewed resident files and 6 of 8 residents do not have updated needs and services plans. LPA reviewed resident medications and no discrepancies were observed. LPA reviewed that the last fire drill was conducted on January 19, 2026. LPA reviewed a fire alarm test from Hilltop Alarms Inc. stating that the fire alarms were tested on April 14, 2025 and passed.

Based on todays inspection, deficiencies and a technical violation are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D, 858, 859, technical violation and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2026 04:53 PM - It Cannot Be Edited

Created By: Hanna Gough On 03/11/2026 at 04:47 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: ANAHEIM VILLA	FACILITY NUMBER: 306006387
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 5 staff not having updated 20 hours of annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee stated they will train staff and send proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC809 (FAS) - (06/04)

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