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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006602
Report Date: 07/21/2026
Date Signed: 07/21/2026 04:36:15 PM

Document Has Been Signed on 07/21/2026 04:36 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HUMBLE HEART HOMEFACILITY NUMBER:
306006602
ADMINISTRATOR/
DIRECTOR:		LEE, LADY YVETTEFACILITY TYPE:
740
ADDRESS:811 N PAULINE STREETTELEPHONE:
(626) 715-4853
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 4CENSUS: 3DATE:
07/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Lady Yvette Lee - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit.
The facility is licensed for four non-ambulatory residents of which one may be bedridden and has a hospice waiver for three. The facility is a 3 bedroom and 1 bathroom home.
During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in resident bathroom. The hot water temperature measured at 111.2 Fahrenheit and all smoke detectors were operational. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed Resident 2 (R2) had half rails without a physician's order. The facility has not conducted any emergency drills. LPA observed a rollaway bed in bedroom 2 , per staff it is used for staff sleep in the living room. LPA observed a large tub of laundry detergent unsecured in facility kitchen. LPA observed unsecured medications in small refrigerator near the kitchen table. LPA observed unsecured sharps in facility kitchen.
LPA reviewed five out of six staff fingerprint records. LPA did not observe current staff training records. Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) were not associated to the facility and have worked multiple days. LPA conducted a complete review of resident records. Resident records contained all the required documentation. LPA confirmed that administrator has a current administrator certificate which expires October 10, 2027.

Based on observations made during today's visit deficiencies are being cited per Title 22. A copy of this report and appeal rights were provided to facility representative.
Alisa Ortiz
Andrea Mendivil
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
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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Document Has Been Signed on 07/21/2026 04:36 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 07/21/2026 at 01:32 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: HUMBLE HEART HOME
FACILITY NUMBER: 306006602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the rollaway bed is used for staff sleeping in the living room. This poses an immediate health and safety to persons in care.
POC Due Date: 07/22/2026
Plan of Correction
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Administrator will remove rollaway bed from bedroom 2 and place in storage.
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 cited above as there were unsecured laundry soap in facility kitchen. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/22/2026
Plan of Correction
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Corrected during visit.
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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/21/2026 04:36 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 07/21/2026 at 01:32 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: HUMBLE HEART HOME
FACILITY NUMBER: 306006602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 administrator did not comply with the cited above as there was unsecured medications in the small refrigerator near the kitchen table. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/22/2026
Plan of Correction
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Corrected during visit
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed the administrator did not comply with the cited above in 1 out of 3 residents, R2 does not have physician's orders for a half rail on their hospital bed. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Administrator requested a physician's order from R2's responsible party for the half rails. Administrator will forward the order to LPA prior use of half rails.
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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2026 04:36 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 07/21/2026 at 02:06 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: HUMBLE HEART HOME
FACILITY NUMBER: 306006602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

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 cited above in 5 out of 6 staff members as none of the staff had any recorded training. This poses a potential health and safety risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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Administrator stated will conduct trainings per HSC 1569.625 and 1569.69 and provide proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
(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 observations and records reviewed the licensee did not comply with the cited above as facility has not conducted any emergency drills . This poses a potential health and safety risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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Administrator stated will create an emergency drill log and conduct Quarter 3's emergency drill. Administrator will provide 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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2026 04:36 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 07/21/2026 at 04:07 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: HUMBLE HEART HOME
FACILITY NUMBER: 306006602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed the licensee did not comply with the cited above in 3 out of 6 staff members as they are not associated to the facility. S1, S2 and S3 were not associated to the facility but all have background clearances. This poses an immediate health and safety risk to persons in care.
POC Due Date: 07/22/2026
Plan of Correction
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Administrator will associate all staff and provide proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4
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:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2026


LIC809 (FAS) - (06/04)
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