306006685-8-18-2026-22-AS-MTEA-DX3PD6-20260818111300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006685
Report Date: 08/18/2026
Date Signed: 08/18/2026 11:13:09 AM

Document Has Been Signed on 08/18/2026 11:13 AM - 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:	BEVERLY RESIDENTIAL CARE		FACILITY NUMBER:	306006685
ADMINISTRATOR/ DIRECTOR:	DINH, KEVIN DINO		FACILITY TYPE:	740
ADDRESS:	9771 BEVERLY LANE		TELEPHONE:	(714) 300-4540
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS: 6	DATE:	08/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Kevin Dinh		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced annual required inspection of the facility. Upon arrival, LPA Tea was greeted by Administrator (AD) Kevin Dinh, who granted entry into the facility. LPA Tea explained the purpose of the visit. The facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden in Room #3. The facility also has an approved hospice waiver for six (6) residents. At the time of the inspection, six (6) residents were in care, three (3) of whom were receiving hospice services.

LPA Tea reviewed six (6) resident files and two (2) staff files. The files reviewed contained the required documentation. AD Dinh's Administrator Certificate expires on October 14, 2027.

LPA Tea and AD Dinh toured the facility. The single-story home consists of three (3) resident bedrooms, one (1) staff room, three (3) bathrooms, a living room, dining area, kitchen, laundry area, detached garage, and backyard. Smoke detectors and carbon monoxide detectors were tested and found to be operational.

Resident bedrooms were observed to be clean and furnished with the required furniture, bedding, and adequate storage space. Resident bathrooms were clean and in good repair. Toilets, sinks, and showers were functioning properly. Grab bars were securely installed, and no mold or mildew was observed. Hot water measured at 116.4 degrees Fahrenheit. Towels, toiletries, and personal hygiene supplies were adequately stocked.

(Annual inspection continued on LIC809-C)

Lourdes Montoya
Michael Tea
	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

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: BEVERLY RESIDENTIAL CARE	FACILITY NUMBER: 306006685
	VISIT DATE: 08/18/2026

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Common areas were clean, orderly, and free of hazards. Hallways and exits were unobstructed. The first aid kit contained the required supplies. Kitchen appliances were operational. Perishable and nonperishable food supplies met regulatory requirements. Sharps and toxic substances were locked and inaccessible to residents. Fire extinguishers were fully charged and properly maintained. The facility's most recent emergency disaster drill was conducted on July 1, 2026. Emergency food and water supplies were available.

Outdoor areas were clean and safe and provided shaded seating for residents. An exit gate was located on the right side of the property and was observed to be functioning properly.

Medications were stored in a locked cabinet in the kitchen area and were administered according to physicians' orders. LPA Tea interviewed residents regarding the quality of care and spoke with staff regarding the services provided at the facility. During the inspection, residents were observed watching television and participating in exercises. AD Dinh reported that, depending on their physical abilities and condition, residents participate in activities that include exercising, listening to music, walking, and spending time in the backyard.

Based on observations, record reviews, and interviews conducted during today's inspection, the facility was found to be in compliance with the areas inspected. No deficiencies were cited under Title 22, Division 6 of the California Code of Regulations.

This report was reviewed with the facility. Copies of the LIC809, LIC809-C, LIC858, and LIC859 were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC809 (FAS) - (06/04)

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