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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006406
Report Date: 05/20/2026
Date Signed: 05/20/2026 12:01:24 PM

Document Has Been Signed on 05/20/2026 12:01 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:HILLS OF BROADWAY, THEFACILITY NUMBER:
306006406
ADMINISTRATOR/
DIRECTOR:		MIRANDA, ROSENDO CFACILITY TYPE:
740
ADDRESS:354 BROADWAYTELEPHONE:
(714) 430-7672
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
05/20/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Karina VillavazoTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 112.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed five residents having breakfast in the dining area and one resident in their room.

The Department began proceedings to revoke the license for the facility effective May 7, 2026. The facility is required to notify all residents and responsible parties in writing within 10 days regarding the commencement of revocation of the license. LPA spoke to five out of six responsible parties over the phone. The five responsible parties have not been notified of the commencement of revocation of the license. There is no notification of the proceedings to revoke the license posted at the facility for review.

Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
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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Document Has Been Signed on 05/20/2026 12:01 PM - It Cannot Be Edited


Created By: Fred Arias On 05/20/2026 at 11:30 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 BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2026
Section Cited
HSC
1569.38(b)(1)

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1569.38(b)(1) Posting of licensing reports
A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following...:
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AD stated all responsible parties and ombudsman will be notified by certified mail regarding the commencement of revocation. AD to submit proof to LPA by POC due date.
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The department commences proceedings to... revoke the license of the facility...
The requirement is not met as evidenced by:
Five responsible parties have not been notified of the proceedings which poses an immediate health and safety risk to persons in care.
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Type A
05/21/2026
Section Cited
HSC1569.38(e)

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1569.38(e) Posting of licensing reports Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include posted... any other easily accessible location in the facility. The
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AD stated the legal accusation document will be posted at the facility. AD to send photo of posting to LPA by POC due date.
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posting shall include all of the following information:
The requirement is not met as evidenced by:
LPA did not observe any posting regarding the revocation at the facility. This poses an immediate health and safety 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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