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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006406
Report Date: 08/07/2026
Date Signed: 08/07/2026 05:30:42 PM

Document Has Been Signed on 08/07/2026 05:30 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:		BALIGNASAY, SHALEEMARFACILITY TYPE:
740
ADDRESS:354 BROADWAYTELEPHONE:
(714) 430-7672
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
08/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Allen Medina, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On August 7, 2026, Licensing Program Analysts (LPAs) Taylor Simerly and Joseph Alejandre conducted an unannounced annual visit. LPAs were greeted and granted entry by Staff. LPAs explained the purpose of today’s visit. Staff attempted to call both of the licensees but did not get an answer. Licensee (LI) Allen Medina later called back and stated that he would be on his way to the facility. LI arrived to help support the remainder of the visit. The facility is licensed to serve six elderly adults, of which six can be non-ambulatory. The facility has an approved hospice waiver for five. Currently the facility has four residents.

The home consists of 6 resident bedrooms, living room with a screened fireplace, dining room, and kitchen as well as 4 bathrooms and a two car garage.


LPAs and staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPAs observed the PUB 475 poster, posted in the living room. LPAs inspected residents’ bedrooms and bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. LPAs observed each resident had a half bed rail on their bed. One out of four residents (R1) does not have an order for bed rails. Bathroom one did not have an operational light and bathroom two did not have an operational shower light, both bathrooms were clean and plumbing fixtures all worked. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 106°F to 111.8°F, and a comfortable temperature throughout.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

Alfonso Iniguez
Taylor Simerly
DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2026
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 11
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 BROADWAY, THE
FACILITY NUMBER: 306006406
VISIT DATE: 08/07/2026
NARRATIVE
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During the visit, LPAs observed that the facility was clean and appropriately furnished. LPAs observed the 3 ceiling lights in the hallway were not operational. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there were sufficient perishable and non-perishable food available, which was adequately maintained. The cook-top range did not have the knobs removed for safety. The fire extinguisher in the kitchen was charged and operable. The last fire drills were not available for review. The facility does not have a first aid kit on site, a citation is being issued. The backyard has a dedicated shaded area for resident use. There are no bodies of water located in the backyard and the gates were operational.

A review of (4) residents' service files and (3) staff personnel files was conducted. R1 did not have a signed Admission Agreement and R1 and R4 did not have Need Care Plans on file. S1, S2 and S3 were missing training on file. S1 did not have a file at the facility. There was no health screening, CPR training or initial training documents for S1. LPA reviewed (1) Medication Administration Records (MARs) and found discrepancies. R2 was missing two medications that they are prescribed, Docusate-Senna and Xyzal. Medication was also found unsecured in the kitchen island. Facility has a dedicated internet device for resident use.

LPAs observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See D page for details.

An exit interview was conducted, and a copy of the Facility Evaluation Report and appeal rights were provided to Allen Medina, Licensee.

NAME OF LICENSING PROGRAM MANAGER: Alfonso Iniguez
NAME OF LICENSING PROGRAM ANALYST: Taylor Simerly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in which S1 does not have CPR training on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2026
Plan of Correction
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2
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Licensee will send LPA Simerly proof of CPR training by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in which S1 did not have a health screening and TB test which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2026
Plan of Correction
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Licensee will send LPA Simerly proof of health screening and TB test 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(16)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in which R2 did not have all prescribed medications at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2026
Plan of Correction
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Licensee will send LPA Simerly proof of medication by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which medication was left unsecured in the kitchen island which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2026
Plan of Correction
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Licensee will provide additional training to staff regarding securing medication and immediately lock up all medication. Proof of training will be sent to LPA Simerly 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)(1)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which stove knobs were left unsecured when not in use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
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2
3
4
Licensee will secure or remove knobs to kitchen stove when not in use. Licensee will send proof to LPA Simerly 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 which S1, S2, and S3 did not have updated training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
1
2
3
4
Licensee will ensure all staff have updated training and send proof to LPA Simerly 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which the facility did not have a first aid kit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
1
2
3
4
Licensee will send proof of first aid kit at facility by POC due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

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 R1 did not have a signed admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
1
2
3
4
Licensee will send proof of signed admission agreement to LPA Simerly 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:27 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in which the facility does not have documented drills on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
1
2
3
4
Licensee will send proof of drills to LPA Simerly by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in which R1 does not have doctors orders for half bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
1
2
3
4
Licensee will remove the half bed rails or get an order from R1's doctor and send proof to LPA Simerly 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 08/07/2026 05:30 PM - It Cannot Be Edited


Created By: Taylor Simerly On 08/07/2026 at 04:45 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: HILLS OF BROADWAY, THE
FACILITY NUMBER: 306006406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which S1 did not have any training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
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Licensee will send LPA proof of training for S1.
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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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