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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006530
Report Date: 08/27/2026
Date Signed: 08/27/2026 05:41:18 PM

Document Has Been Signed on 08/27/2026 05:41 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:FAMILY TIES SENIOR LIVINGFACILITY NUMBER:
306006530
ADMINISTRATOR/
DIRECTOR:		RAJPOOT, FAISALFACILITY TYPE:
740
ADDRESS:6096 SHERIDAN WAYTELEPHONE:
(657) 239-0217
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 12CENSUS: 7DATE:
08/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Faisal RajpootTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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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 that includes an Additional Dwelling Unit (ADU) and licensed for 12 residents. Seven resident were present during the inspection. There’s a total of 7 bedrooms (6 resident and 1 staff room) and 4 restrooms available. There’s a living room space, a dining space, backyard area and an attached garage. The ADU also has an attached garage. Bedrooms: All bedrooms have the required furnishings. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured at 112.1 degrees F. Cleaning chemicals are locked below the sink. Kitchen: 4 of 4 burners and the warmer were operational on the gas stove. All four burners were operational on the gas stove in the ADU as well. Sharps are double locked and stored in a locked filing cabinet behind the dining table in a locked safe. Resident medication are stored in a locked kitchen cabinet. Food Service: A food supply that meets regulation requirements was observed.
Client & Staff Files: Resident and staff files are located in locked filing cabinet behind the dining table.
File Review: Four resident files and three staff files were reviewed during the inspection.

Medications/First-Aid Kit: Client medications are stored in a locked kitchen cabinet. A first aid kit with all the required elements was observed in the locked filing cabinet behind the dining table



Medication Review: Three resident medication were reviewed during the visit.

Continued on LIC809C
Kevin Saborit-Guasch
Jerome Haley
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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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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: FAMILY TIES SENIOR LIVING
FACILITY NUMBER: 306006530
VISIT DATE: 08/27/2026
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Linens & Hygiene Supplies: Hygiene items were observed in the resident bathrooms. Additional linens were observed in the closets in the main hallway.

Garage Area: Walkways are free of obstruction. A laundry area equipped with a washer and dryer was observed. An additional perishable food supply was observed in a refrigerator, and a nonperishable food supply was observed in the pantry in the garage. Emergency items were observed including a supply of emergency food and water.

Backyard/Exterior: A table and chairs were observed under a shaded patio area. There’s a storage shed in the backyard with an additional nonperishable food supply.

Bodies of Water: None
Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.
Fire Extinguisher: Fire extinguishers was observed mounted on the wall in both kitchens.

An emergency evacuation drill: Conducted August 22, 2026, and are conducted quarterly.

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


Facility postings are posted are available for review on the postings board in the main hallway.

No deficiencies are being cited as a result of today’s inspection.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
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