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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006519
Report Date: 04/09/2025
Date Signed: 04/09/2025 02:13:00 PM

Document Has Been Signed on 04/09/2025 02:13 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:B&C SENIOR LIVINGFACILITY NUMBER:
306006519
ADMINISTRATOR/
DIRECTOR:		EUGENIO, JOHN JASONFACILITY TYPE:
740
ADDRESS:1354 N FERNDALE ST.TELEPHONE:
(714) 488-8413
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:11 PM
MET WITH:Brian EstorbaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to perform a required annual inspection. Upon arrival, LPA was greeted by Administrator (AD) Brian Estorba and was granted entry into the facility. LPA explained the purpose of the visit, and the inspection proceeded with AD accompanying LPA throughout the tour of the facility’s interior and exterior areas.

Observations:

The facility is a one-story house with a 2 car garage with 5 bedrooms (1 is for staff), 3 bathrooms, dining room/living room, and a kitchen.

Resident bedrooms were furnished with a bed, chair, clean linens, and adequate storage space, and were free of tripping hazards. Safety equipment, including manual smoke detectors, carbon monoxide detectors, and exit alarms, was tested and confirmed operational. Bathrooms were in good condition, equipped with grab bars. LPA found chemicals supplies in bathroom 1 under the sink and chemicals were accessible to residents in care.

Furthermore, LPA checked hot water and was measured at 133. 6°F. The kitchen was clean and in good repair, however cleaning supplies and sharp objects were on the kitchen counter and in plain view with immediate access to residents in care. Also, LPA observed Medication cabinet in the kitchen unlocked and unsecure.

The facility maintained a minimum two-day supply of perishable food and a seven-day supply of non-perishable food, meeting regulatory standards. The fire extinguisher was inspected, with the last service date recorded as March 22nd, 2025.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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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: B&C SENIOR LIVING
FACILITY NUMBER: 306006519
VISIT DATE: 04/09/2025
NARRATIVE
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Exterior: the facility did not have any outdoor furniture, nor shaded area for residents to practice any activity. LPA noticed the emergency exits to be blocked by extra storge items which put the safety of residents in jeopardy. The grass was not maintained nor had been cut. LPA checked the garage and could not perform the inspection due to it being used as storge and items were in boxes stacked 6-feet high all around and in the middle of the garage.

LPA reviewed three resident files and their corresponding medications, noting no discrepancies. Similarly, two staff files were examined, with all required documentation present and no issues identified. Facility records confirmed facility was not in compliance with quarterly fire drills, in which an advisory note was issued.

Findings:

Based on the above observation made today, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights provided to AD at end of inspection.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/09/2025 02:13 PM - It Cannot Be Edited


Created By: Samer Haddadin On 04/09/2025 at 01:40 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: B&C SENIOR LIVING
FACILITY NUMBER: 306006519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 having items blocking the emergency exits which poses an immediate health, safety to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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AD is to clean and remove items in backyard and submit proof to LPA by POC due date
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 having hot water temperature measured 133.6 DF which poses an immediate health, safety risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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AD to send proof of hot water temperature measurining between 105 and 120 to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/09/2025 02:13 PM - It Cannot Be Edited


Created By: Samer Haddadin On 04/09/2025 at 01:40 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: B&C SENIOR LIVING
FACILITY NUMBER: 306006519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 having chemicals, sharps and cleaning supplies accessible to residents which poses an immediate health, safety to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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LPA observed AD securining all sharps and chemicals. AD to train staff and send proof to LPA 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 having medication unsecured and accessible to residents which poses an immediate health, safety to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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LPA observed AD securining medication. AD to train staff and send proof to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/09/2025 02:13 PM - It Cannot Be Edited


Created By: Samer Haddadin On 04/09/2025 at 01:40 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: B&C SENIOR LIVING
FACILITY NUMBER: 306006519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 having the indoor garage full of storage items which poses a potential health, safety to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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AD to clean the garage and have space for LPA to inspect area. AD to send proof to LPA by e mail by POC due date
Type B
Section Cited
CCR
87219(h)
Planned Activities
(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of:

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 not having shaded area nor furniture for clients to perform any activity which poses a potential health and safety to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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LPA to buy outside furniture for residents' enjoyment and send proof to LPA 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Samer Haddadin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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