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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006529
Report Date: 09/15/2025
Date Signed: 09/15/2025 03:12:02 PM

Document Has Been Signed on 09/15/2025 03:12 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:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR/
DIRECTOR:		ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
09/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:Staff on duty - Jackelin MijaresTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced required visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted facility administrator (AD) Nargis Elahi about visit. AD Elahi designated for staff on duty (S1) Jackelin Mijares to receive and sign report due to AD Elahi being unavailable.

The PUB475 "See Something, Say Something" poster was observed to be located at the entrance of the facility. LPA observed the Administrator's Certificate for Nargis Elahi, which expires on 11/11/2026.

LPA toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 1 may be bedridden in room #1 and 6 may be on hospice. For this visit, there are a total of 5 residents in care, of which 0 are on hospice and 0 are bedridden.

There are a total of 7 bedrooms, of which 6 are private resident rooms, and 1 bedroom for staff. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms, of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature was measured to be at 108.8 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529
VISIT DATE: 09/15/2025
NARRATIVE
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen and the hallway. Fire extinguishers were dated and tagged for the date of 2025. LPA observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. Medications and toxins were also observed to be locked and inaccessible to residents in care.

For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which were self-closing and self-latching. No bodies of water were observed.

For today's visit deficiencies and a civil penalty was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with S1 Mijares and AD Elahi via phone call.

A copy of this report and appeal rights were explained and provided at the end of visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 03:12 PM - It Cannot Be Edited


Created By: Celine Rodriguez On 09/15/2025 at 01:56 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: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(a)
87355 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above. 1 out of 2 staff members did not complete and obtain results of background clearance. LPA obtained confirmation from staff 2 (S2) and facility administrator that S2 has been presently working at the facility as of 9/6/2025. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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As a plan of correction (POC) facility is obtain a completed background clearance for S2 and all current staff members and is to associate all staff on Guardian on or by 9/16/2025.
Type A
Section Cited
CCR
87458(c)(1)(A)
87458 Medical Assessment
(c) The medical assessment shall include...
(1) ...results of an examination for...
(A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record reviews, the licensee did not comply with the section cited above. Facility did not complete a tuberculosis screening for resident 1 (R1) and resident 2 (R2). This poses an immediate health and safety risk to residents in care.
POC Due Date: 09/16/2025
Plan of Correction
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As a plan of correction (POC) facility will schedule for R1 and R2 appointments to complete a TB exam and submit proof to assigned LPA on or by 9/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Celine Rodriguez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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