306005361-10-14-2026-22-AS-TSIY-DYUQ5A-20261014115137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 10/14/2026
Date Signed: 10/14/2026 04:16:11 PM

Document Has Been Signed on 10/14/2026 04:16 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:	SPRINGWELL HAVEN, LLC		FACILITY NUMBER:	306005361
ADMINISTRATOR/ DIRECTOR:	RAMIL DE LOS SANTOS		FACILITY TYPE:	740
ADDRESS:	2424 FRANCISCO DRIVE		TELEPHONE:	(949) 524-3484
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92660
CAPACITY: 6		CENSUS: 5	DATE:	10/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Cybele Magtibay, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:05 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) Taylor Simerly made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by staff. Cybele Magtibay, Administrator (AD) later arrived to help support the visit. The AD has a valid administrator certificate through July 3, 2028. The facility has active liability insurance through March 5, 2027. The facility is licensed for six residents, four of which can be non-ambulatory. The facility currently has a census of five in care with two staff on duty. The facility is a single-story home consisting of five client bedrooms, three bathrooms, a kitchen, dining area, care giver room, living room, office/ additional dining room and an attached garage. There is an additional caregiver apartment above the garage. LPA observed the PUB 475 “See Something Say Something” poster posted in the entryway. 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 bathrooms. The hot water temperature measured between 122.1 to 123.6 degrees F. A citation will be issued. LPA noted bathroom toilets were in working order and grab bars and non-skid floor mats were provided. Hygiene supplies, including towels and toiletries, were adequately stocked. The facility was observed to be clean, safe, and well maintained. Smoke detectors and carbon monoxide detectors were operational in both common areas and bedrooms. Client bedrooms were appropriately furnished with beds, linens, and sufficient storage space. The facility’s last fire drill was conducted on August 14, 2026. Fire extinguishers were charged and operable. Continued on the LIC 809C

Alfonso Iniguez
Taylor Simerly
	DATE: 10/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026

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: SPRINGWELL HAVEN, LLC	FACILITY NUMBER: 306005361
	VISIT DATE: 10/14/2026

NARRATIVE

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LPA toured the exterior and observed a shaded seating area for client use, no hazards or obstacles were observed. There is a fountain in the backyard with rocks to help support excess water. There are two gates in the backyard, one does not fully close. A citation will be issued.

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. Sharp items and knives were located in the kitchen and were locked and inaccessible to residents. Facility had back-up emergency food and water supply located in the pantry. Cleaning supplies were locked and stored away from food.

Medication storage and administration practices were reviewed. Medications were securely stored in a locked cabinet and administered in accordance with physician order. LPA reviewed the centrally stored medications for all five residents and no discrepancies observed. The First Aid Kit has all of the required elements.

LPA reviewed two staff files and all five resident files. No discrepancies were noted in the staff or resident files.

LPA conducted interviews with staff and residents regarding the quality of care and services provided.

The following deficiencies are being cited per Title 22 Division 8 of the California Code of Regulations.
An exit interview was conducted with Administrator, Cybele Magtibay and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alfonso Iniguez
NAME OF LICENSING PROGRAM ANALYST: Taylor Simerly
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2026 04:16 PM - It Cannot Be Edited

Created By: Taylor Simerly On 10/14/2026 at 11:38 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: SPRINGWELL HAVEN, LLC	FACILITY NUMBER: 306005361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in which one out of two exterior gates are not self-latching which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2026
	Plan of Correction
1 2 3 4	Licensee will send proof of gate being fixed to LPA by POC due date.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which the water measured between 122.1 to 123.6 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2026
	Plan of Correction
1 2 3 4	Licensee will sent proof of updated water temperature and water temperature log 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.

	Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:

	Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2026

LIC809 (FAS) - (06/04)

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