306006624-5-22-2026-22-AS-JCHO-DUBUY4-20260522155919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006624
Report Date: 05/22/2026
Date Signed: 05/22/2026 03:59:28 PM

Document Has Been Signed on 05/22/2026 03:59 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:	PALMS BAY GUEST HOME		FACILITY NUMBER:	306006624
ADMINISTRATOR/ DIRECTOR:	MARICA, ABEL		FACILITY TYPE:	740
ADDRESS:	13032 LAIRD STREET		TELEPHONE:	(949) 232-9619
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY: 6		CENSUS: 4	DATE:	05/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Claudia Olteanu- Administrator Mary Christine Alfaro- Administrator's Assistant		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Eddie Agnote after introducing self and stating the reason for the visit. Administrator's Assistant (Admin Asst.) Mary Christine Alfaro followed by Administrator Claudia Olteanu shortly arrived to assist with the inspection. Administrator Claudia Olteanu has a valid certificate expiring on June 13, 2026. The following was observed during the inspection accompanied by Caregiver Agnote: This is Residential Care Facility for the Elderly (RCFE) vendorized by the Regional Center of Orange County. This is a level 6 home. The facility is located in a residential neighborhood comprised of four private resident bedrooms and two resident full bathrooms. LPA observed four residents in care, none of which are currently on hospice and bedridden. LPA observed three staff present and two on duty. Facility is operating within the conditions and limitations specified on the license. LPA toured the physical plant. LPA inspected all common areas including the attached two car garage and all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. Facility appeared clean, sanitary, and in good repair as well as the bathrooms. Slip resistant mats were observed to be available. The hot water temperature in the resident bathrooms measured within range measuring at 118.0 and 118.5 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two-day supply of perishables and seven-day supply of non-perishable food.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026

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 3

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 3

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: PALMS BAY GUEST HOME	FACILITY NUMBER: 306006624
	VISIT DATE: 05/22/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA toured the exterior portion of the facility. The Additional Dwelling Unit (ADU) is approved per the fire clearance. LPA observed two bedrooms and one bathroom designated for staff. The outdoor passageway is free of obstruction, and there are sufficient seating and shading in the patio area. There are no bodies of water on premise and two sheds are secured and inaccessible. The first aid kit contains all necessary elements. The two fire extinguishers were mounted, charged, and serviced on January 22, 2026. The auditory devices and smoke/carbon monoxide detectors were tested and operational in all areas. Facility maintains emergency food, water. and disaster supplies. A working telephone (714) 583-8555 was tested and remains available. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the entry way in the correct size.

LPA reviewed four residents and two personnel files. No discrepancies noted. Present staff are background cleared and associated to the facility. Staff met their annual 40 and 20 hour training. The Emergency Disaster Plan (LIC610E) was reviewed. Disaster drills of various scenarios are conducted quarterly with the last known date was April 14, 2026. Medications were audited for two of four residents. Admin will verify the order for a medication for Resident #1 (R1).

Based on the observations made during today's visit, no deficiency is being cited.

An exit interview was conducted with Administrator Claudia Olteanu and Administrator's Assistant Mary Christine Alfaro, and a copy of this report was provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3