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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006491
Report Date: 10/13/2025
Date Signed: 10/13/2025 03:29:46 PM

Document Has Been Signed on 10/13/2025 03:29 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:STANTON BOARD AND CARE HOMEFACILITY NUMBER:
306006491
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, GREGFACILITY TYPE:
735
ADDRESS:8296 STANTON AVENUETELEPHONE:
(714) 816-5043
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
10/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Maria MendozaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


The facility is a single level structure and licensed for six ambulatory clients. As of today, the facility has six clients admitted to the facility. There’s a total of 6 bedrooms of which, four bedrooms are for the clients, one bedroom is for staff, and one bedroom is currently vacant. There are two restrooms available. There’s a living room space, a dining space, a backyard area, and an office. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in between 105 degrees F. Kitchen: 4 of 4 burners and the warmer are operational on the gas stove. No sharps or chemicals are stored in the kitchen. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.
Client & Staff Files: Client and staff files are located in the locked office area in filing cabinet(s).
File Review: 3 of 6 client files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Client medications are stored in a filing cabinet in the locked office. A first aid kits with all the required elements is located in the office in the cabinet with the client files.


Medication Review: 3 of 6 client medications were reviewed during the visit.
Linens & Hygiene Supplies: Hygiene caddy’s were observed in clients bedrooms.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2025
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 10/13/2025 03:29 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/13/2025 at 02:45 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: STANTON BOARD AND CARE HOME
FACILITY NUMBER: 306006491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of a broken curtain rail/rod in a clients room and a damaged window screen with multiple areas being held together by green duck tape, the licensee did not comply with the section cited above which poses a safety and/or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Facility representative agrees to inform Licensee/Administrator Hernandez the repairs or replacement(s) for the curtain rail/rod in the clinets room and the damaged sliding glass door screen needs to be completed and photos need to be emailed to LPA Haley by 4:00pm on Friday, October 17, 2025.
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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2025


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: STANTON BOARD AND CARE HOME
FACILITY NUMBER: 306006491
VISIT DATE: 10/13/2025
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Office Area: The locked office is clean and well organized with a desk and a printer. The walkways were free of obstruction. There's a supply of nonperishable items that meet regulation requirements. Emergency water was observed. A washing machine was observed in the office area. Additional cleaning supplies were observed, an additional refrigerator with an additional food supply was observed as well.
Backyard/Exterior: The backyard is clean and very well organized. Walkways are free of obstruction. A table with some chairs was observed under a shaded patio area.

Bodies of Water: None
Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers were observed mounted on a wall in the kitchen and another extinguisher was observed on a desk in the living room area.

An emergency evacuation drill: Was conducted July 25, 2025. Evacuation drills are conducted quarterly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:


Several facility postings are posted are available for review on the postings board in the open office area near the kitchen.

Additional Comments: Annual fees are current. Facility contact information was reviewed and confirmed. 3 client P&I funds were reviewed, and 3 client medications were reviewed. No discrepancies were noted with the P&I funds or the client medications.

A deficiency and a Technical Violation are being cited as a result today’s visit

An exit interview conducted, and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
LIC809 (FAS) - (06/04)
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