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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004839
Report Date: 10/02/2026
Date Signed: 10/02/2026 09:29:46 AM

Document Has Been Signed on 10/02/2026 09:29 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:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR/
DIRECTOR:		JAE WAN RIMFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 197CENSUS: 178DATE:
10/02/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Jae Wan RimTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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On October 2, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the findings regarding a Case Management visit conducted to the facility on November 20, 2025. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted on today’s visit.

On November 19, 2025, the Orange County Regional Office received a self reported unusual incident report from the facility reporting the death of Resident #1 (R1). The unusual incident report stated that on November 19, 2025, R1 choked on their food and passed away at the facility. During the course of the investigation, the Department interviewed staff, reviewed and obtained pertinent documents for this incident. The investigation into this incident revealed the following: R1 was admitted to the facility on May 9, 2022. Per R1’s Preplacement Appraisal Information and Resident Appraisal dated May 9, 2022, it described R1 as having dementia, being confused, and in overall poor condition. It also described R1 as needing significant assistance with activities of daily living (ADLs), such as with transferring, bathing, medication, incontinence care, and with eating. It also states that R1 was on a mechanically soft diet and needed supervision with eating. Per R1’s Physician’s Reports dated May 10, 2022, June 20, 2023, and July 9, 2024, R1’s diagnoses included hepatitis B, mild cognitive impairment, and dysphagia. The documentation also states that R1 is able to feed self with supervision, was on a prescribed mechanical soft diet, required continuous bed care, and was considered bedridden. Additional documentation such as R1’s Resident Appraisal and Needs and Services Plan dated July 15, 2024, demonstrate that R1’s condition did not improve while at the facility and that they required continuous supervision while eating. The Needs and Services Plan also did not indicate a plan for assisting and supervising R1 with meals.

CONTINUED ON LIC809-C

Sheila Santos
Brandon Lopez
DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2026
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: FULLERTON VILLA
FACILITY NUMBER: 306004839
VISIT DATE: 10/02/2026
NARRATIVE
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During the investigation, the Department conducted six staff interviews. Staff interviews revealed that on November 19, 2025, Staff #3 (S3) delivered a food tray to R1’s bedroom for lunch. S3 then exited R1’s bedroom to pass food trays to other residents. S3 then returned approximately ten to fifteen minutes later and observed R1 to be choking. S3 then called for assistance, and when no one responded, S3 left R1’s bedroom while they were choking, to get assistance from the on-duty nurse, Staff #6 (S6). S6 described R1 as already blue and with no body reaction once they arrived to the bedroom. 9-1-1 was then called while S6 performed the Heimlich maneuver. The Heimlich maneuver was unsuccessful and cardiopulmonary resuscitation (CPR) was not performed due to R1 having a do not resuscitate (DNR) order on file. R1 then passed away at the facility shortly afterwards. Staff interviews confirmed that R1 was not being supervised as they were eating on November 19, 2025, as required by their records. Staff interviews also confirmed that 9-1-1 was not immediately called when R1 was first observed to be choking on their food, despite R1 actively experiencing a life-threatening emergency. Emergency medical service (EMS) records dated November 19, 2025, described R1 as being found on the floor in a left lateral position with partially chewed food obstructing their airway. The records also describe the incident as an obvious death. Per R1’s certificate of death dated November 19, 2025, R1’s immediate cause of death is listed as choking on food bolus.

Based on the evidence gathered during this investigation, citations will be issued on the attached LIC809-D page. Two civil penalties in the amount of $500.00 each will be assessed on the attached LIC421IM pages. An additional civil penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49.

An exit interview was conducted with Administrator Jae Wan Rim. A copy of the report and appeal rights were provided at time of visit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2026 09:29 AM - It Cannot Be Edited


Created By: Brandon Lopez On 10/02/2026 at 09:04 AM
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: FULLERTON VILLA
FACILITY NUMBER: 306004839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2026
Section Cited
CCR
87464(f)(1)

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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not evidenced by:
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The Administrator stated that he will conduct an in-service training with all facility staff regarding providing adequate supervision to residents according to their care plan. In addition, a written plan will be submitted to CCL to ensure supervision is always provided. The Administrator agreed to
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Based on records reviewed and interviews conducted, the Licensee did not ensure that R1 was adequately supervised while eating, resulting in R1 choking on her food and passing away at the facility on November 20, 2025. This posed an immediate health and safety risk to persons in care.
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to provide LPA proof of training and the wrriten plan via email or fax by POC date.
Type A
10/03/2026
Section Cited
CCR87465(g)

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87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including.. an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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The Administrator stated that he will conduct an in-service training with all facility staff regarding immediately calling 9-1-1 during incidents that are an imminent threat to a resident’s health. In addition, a written plan will be submitted to CCL to ensure supervision is always provided.
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This requirement is not evidenced by:
Based on interviews conducted, the Licensee did not ensure that staff immediately called 9-1-1 once they observed R1 to be choking on their food. This poses an immediate health and safety risk to persons in care.
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 The Administrator agreed to provide LPA proof of training and the written plan via email or fax by POC 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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