306006406-8-18-2026-22-AS-RMRT-DX3TVE-20260818150348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006406
Report Date: 08/18/2026
Date Signed: 08/18/2026 03:03:57 PM

Document Has Been Signed on 08/18/2026 03:03 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, THE		FACILITY NUMBER:	306006406
ADMINISTRATOR/ DIRECTOR:	BALIGNASAY, SHALEEMAR		FACILITY TYPE:	740
ADDRESS:	354 BROADWAY		TELEPHONE:	(714) 430-7672
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 3	DATE:	08/18/2026
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Shaleemar "Shy" Balignasay, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for a Case Management. LPA was greeted by Staff at 1:30pm and met with Administrator (AD) Shaleemar "Shy" Balignasay and explained the purpose of the visit. At time of entry the facility had a census of three residents. Three of three residents were in their bedrooms reclining after lunch. One resident was observed in bed reading a book and two were taking afternoon naps. AD Balignasay reviewed the Type A citations that were given on August 7, 2026 with LPA. Emails were also sent to LPA Taylor Simerly for the Type A Plan of Corrections. Medications were in a locked cabinet and a First Aid kit with the required elements was also observed. Three of three residents have complete medication lists and bed rail orders on file. LPA was introduced to two staff members who were background cleared and associated to the facility on August 10, 2026. Two of two new staff have not received their first paychecks until August 22, 2026. LPA reviewed personnel records and staff members had health screenings, tuberculosis testing and First Aid/ Cardiopulmonary Resuscitation Training. Both staff members have the initial hours of training which include: medications, hands-on shadow training, and several emergency disaster trainings. Plan of Corrections were sent to LPA Taylor Simerly. The facility was 79 degrees Fahrenheit and windows were open with a breeze. The facility was clean and all light fixture repairs were completed. A work order for air conditioning repair was placed but the owner will be (Continued on LIC 809-C)

Alisa Ortiz
RoseMarie Ruppert
	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

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: HILLS OF BROADWAY, THE	FACILITY NUMBER: 306006406
	VISIT DATE: 08/18/2026

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(Continued from LIC 809)

changing the air conditioning system within the week. LPA measured the hot water temperatures in two of three resident bathrooms. The hot water temperature ranged from 110.2 to 114.9 degrees Fahrenheit.

LPA confirmed that staff members who were not background cleared or missing health screening files no longer are employed at the facility. Licensee is obtaining a signed Admissions Agreement for one resident. The Administrator is reviewing and updating the Medication Administrator Record (MAR) and safety stove knobs were ordered for Plan of Corrections due on August 21, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Shaleemar "Shy" Balignasay and a copy of the report and files reviewed (LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC809 (FAS) - (06/04)

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