306006866-6-16-2026-22-AS-EBEY-DV4NXM-20260616105122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006866
Report Date: 06/16/2026
Date Signed: 06/16/2026 10:52:53 AM

Document Has Been Signed on 06/16/2026 10:52 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:	CARE CONNECTION SOUTH		FACILITY NUMBER:	306006866
ADMINISTRATOR/ DIRECTOR:	GILBERT, ERIC		FACILITY TYPE:	740
ADDRESS:	17397 PALM STREET		TELEPHONE:	(573) 355-1222
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 5	DATE:	06/16/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Eric Gilbert - Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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	On June 16, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived announced for the purpose of conducting the Pre-Licensing visit for an Initial Application. LPA conducted the visit with Applicant/Administrator Eric Gilbert and family member/Administrator Suzanne Anderson. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on October 8, 2025, for age range 60 and over, with Fire Clearance approved five (5) non-ambulatory residents and one Bedridden in Bedroom #1 only. LPA toured the facility's indoor and outdoor physical plant with Applicant Eric Gilbert and family member. The following were observed: Structure: The facility is a single-story property in a residential neighborhood comprised of five resident bedrooms, three bathrooms, a living room, dining room, two car garage with office, and backyard with outdoor covered seating area. Telephone Number: The facility currently has a land line with the number (657)204-9994. Emergency Phone Numbers/Exit Plan: Posted in the entry way. CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

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: CARE CONNECTION SOUTH	FACILITY NUMBER: 306006866
	VISIT DATE: 06/16/2026

NARRATIVE

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Postings:
The See Something, Say Something (PUB475) was in the correct size, and all required posting available in the entry way.

Food Service and Menu:
Supply of seven-day non-perishable and two-day perishables were observed in the kitchen. The emergency
food/water supply were also available in the garage. LPA observed the Activity Schedule posted.

Smoke and Carbon Monoxide Detectors:
The smoke detectors and carbon monoxide alert systems were tested and found operational.

Fire Extinguishers:
There were two fire extinguishers mounted, fully charged, and purchased on July 20, 2025.

Fire Clearance:
Approved on November 4, 2025, for approved five (5) non-ambulatory residents and one Bedridden in Bedroom #1 only.

Liability Insurance:
Facility does not currently have liability insurance.

Signal System:
No signal system.

Bedrooms:
The residents' bedrooms had all required components, are spacious, and easily accommodate the clients’
furnishings. All rooms and closets contained space for residents’ personal items and belongings.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC809 (FAS) - (06/04)

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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: CARE CONNECTION SOUTH	FACILITY NUMBER: 306006866
	VISIT DATE: 06/16/2026

NARRATIVE

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Bathrooms:
Bathrooms were clean and operational.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies for residents use were fully stocked.

Appliances:
Stove burners, microwave, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records are maintained on site.

Medication:
Medication is secured in a closet near the living room.

Reading Material, Games, Equipment, & Materials:
The facility maintains games and activities in the living room area.

Sharps and Toxins:
Sharps were secured in drawer in the kitchen and inaccessible. Cleaning supplies and toxins were observed in the locked cabinet under the kitchen sink.

Water Temperature:
The water temperature in the three resident bathrooms measured at 108.6 and 111.3 degrees Fahrenheit.

Medications, First Aid Kit, & Manual:
The First Aid Kit and manual were checked and found to be in order.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC809 (FAS) - (06/04)

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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: CARE CONNECTION SOUTH	FACILITY NUMBER: 306006866
	VISIT DATE: 06/16/2026

NARRATIVE

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Component III is waived due to the applicant fulfilling the requirements previously for existing facilities.

On today's visit, the Pre-Licensing is now complete. The license will be granted upon completion of a
final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with the above individuals, and a copy of this report was provided at the time
of this visit.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC809 (FAS) - (06/04)

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