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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006526
Report Date: 08/06/2026
Date Signed: 08/06/2026 04:07:57 PM

Document Has Been Signed on 08/06/2026 04:07 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:KAELA'S HOME FOR ELDERLYFACILITY NUMBER:
306006526
ADMINISTRATOR/
DIRECTOR:		DUMALIANG, CZARINE SFACILITY TYPE:
740
ADDRESS:24176 MCOY ROADTELEPHONE:
(310) 308-0925
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
08/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee- Ser Paris DumaliangTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On August 6, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Licensee (LICEN) Ser Paris Dumaliang.

The facility is licensed to have a capacity of six (6) nonambulatory residents, of which one (1) may be bedridden, and a hospice waiver for six (6) residents. LPA Kim observed the following. The facility is a one-story house with an attached 2-car garage with five (5) resident bedrooms, one (1) staff bedroom, five (5) bathrooms, dining room, a kitchen, a living room, and outdoor shaded area.

LPA Kim toured inside and outside of the physical plant. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be clean and operational. The water temperature in one out of four resident bedrooms measured at 124.1 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents

Evaluation Report Continues on LIC 809-C
Lourdes Montoya
Edward Kim
DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2026
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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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: KAELA'S HOME FOR ELDERLY
FACILITY NUMBER: 306006526
VISIT DATE: 08/06/2026
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water and emergency supplies are stored in the garage. All mandated inspection control posters were posted. The facility has smoke detectors and carbon monoxide detectors that were operable. The Certificate of Liability Insurance is effective from October 25, 2025, to October 25, 2026.

The facility did not have a current or completed Fire/Safety Drills logs at the time of the visit. One (1) fire extinguishers is mounted in the kitchen. A working telephone Facility phone number (949-446-4085) and tablet device dedicated to the residents both remain available. First Aid Kit contained all the necessary elements.

LPA Kim conducted an audit of six (6) residents (R1-R6) files, and seven (7) staff (S1-S7) personnel files, and medication and medication administration records LPA observed R1 did not have a medical assessment in their file. LPA conducted interviews with two residents and two staff. S1 stated they pulled out a pullout bed to the living room or garage to sleep at the facility.

Based on today’s visit, deficiencies were cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed a resident’s bathroom hot water temperature measured at 124.1 degrees F. LPA observed R1 did not have a medical assessment in their file at the time of the visit. LPA observed the facility did not have a completed emergency drill logs in their facility file at the time of the visit. LPA interviewed S1 who stated that they pulled a pullout bed to sleep in the living room or garage to sleep in.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Licensee Ser Paris Dumaliang.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
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)
Page: 2 of 5
Document Has Been Signed on 08/06/2026 04:07 PM - It Cannot Be Edited


Created By: Edward Kim On 08/06/2026 at 02:22 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: KAELA'S HOME FOR ELDERLY
FACILITY NUMBER: 306006526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed R1 did not have a Medical Assessment in their file at the time of the visit. This 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 stated they will send a copy of R1's medical assessment to CCLD via email to edward.kim@dss.ca.gov by POC due date August 21, 2026.
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA did not observe any completed emergency/fire drill log during the time of the visit. This 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 stated they will conduct a drill for this quarter and send a plan of when they will conduct emergency drills from this third quarter 2026 to the fourth quarter of 2027 to CCLD via email to edward.kim@dss.ca.gov by POC date August 21, 2026.
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:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2026


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


Created By: Edward Kim On 08/06/2026 at 02:22 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: KAELA'S HOME FOR ELDERLY
FACILITY NUMBER: 306006526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 and interview, the licensee did not comply with the section cited above two out of four resident bathrooms. LPA observed the one out of four resident bathroom measured at 124.1 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will send a video that the resident bathroom's water temperature is in range and send a hot water temperature log for every hour from August 6, 2026, 5:00 PM to August 7, 2026, 5:00 PM to CCLD via email to edward.kim@dss.ca.gov by POC due date August 7, 2026.
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above. LPA interviewed S1 who stated they used a pull out bed to sleep in the living room one time. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will send photo proof that they got rid of the pullout bed and send proof the facility training plan for all staff on regulation 87307(a)(2)(B) to CCLD via email to edward.kim@dss.ca.gov by POC due date August 7, 2026.
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:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2026


LIC809 (FAS) - (06/04)
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