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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006488
Report Date: 09/26/2025
Date Signed: 09/26/2025 11:21:42 AM

Document Has Been Signed on 09/26/2025 11:21 AM - 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:PACIFIC BOARD AND CARE HOMEFACILITY NUMBER:
306006488
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, DIANAFACILITY TYPE:
735
ADDRESS:7612 PACIFIC AVENUETELEPHONE:
(714) 266-0194
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
09/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maria MendozaTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. Caregiver(CG) Maria Mendoza called Administrator/licensee(AD) Diana Hernandez and LPA discussed the purpose of the visit. AD had CG assistes LPA with the visit and was available by phone. The facility currently has six clients in care of which all are at day program.

The facility is a one story home with six bedrooms, three bathrooms, two living rooms, kitchen and detached two car garage. The facility appears clean, safe and sanitary. LPA observed the client bedrooms had the required components and furnishings. LPA observed one of the bedrooms used as a staff room and it was locked and made inaccessible to clients in care. LPA observed the kitchen to be free clean and free of vermin. LPA observed the stove to have two of four burners working. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed a fire extinguisher in the kitchen to be charged and with a purchase date of June 16, 2025. LPA observed the knives and centrally stored medication to be locked in the hall closet by the front bathroom and made inaccessible to clients in care. LPA observed an ample supply of activities for client use. LPA observed the bathrooms to be stocked with toilet paper, paper towels, and non slip mats in the shower. LPA tested the water to be between 113.9 and 114.9 degrees Fahrenheit. LPA observed the toxins and chemicals to be stored by the outdoor laundry area in a locked outdoor bin and made inaccessible to clients in care. LPA observed the garage to have an extra fridge and freezer for food storage. LPA observed the garage to have open shelving with one used for extra food storage and the other used to store extra toxins and chemicals. LPA observed the garage also is used as an office space for staff but has a lock and is made inaccessible to clients in care. LPA observed the backyard to be free of debris and obstructions. LPA observed a shaded seating area for client use. LPA and CG tested the carbon monoxide and smoke detectors and they were found to be operational. Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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 09/26/2025 11:21 AM - It Cannot Be Edited


Created By: Hanna Gough On 09/26/2025 at 10:47 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: PACIFIC BOARD AND CARE HOME
FACILITY NUMBER: 306006488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

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 obtaining prior to acceptance 2 of 5 client medical assessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee stated they will obtain physicians reports for both clients and send to LPA by POC due date.
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.
Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2025


LIC809 (FAS) - (06/04)
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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: PACIFIC BOARD AND CARE HOME
FACILITY NUMBER: 306006488
VISIT DATE: 09/26/2025
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LPA reviewed staff files and no discrepancies were observed. LPA reviewed five client files and two of five clients do not have a medical assessment on file. AD informed LPA that they do not have the medical assessment for the clients yet. LPA observed one of five clients do not have a completed admission agreement in their file. LPA did observed the first page of the agreement. LPA observed client medications and no discrepancies were observed. LPA and CG reviewed P&I and no discrepancies were observed. LPA observed the last fire drill was conducted on July 30, 2025. All staff present are background cleared and associated to the facility.

Based on today’s inspection, deficiencies and technical violations are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with CG Maria Mendoza and by phone AD Diana Hernandez and a copy of this report along with LIC809D, technical violations 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: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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