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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005680
Report Date: 10/13/2026
Date Signed: 10/13/2026 04:16:40 PM

Document Has Been Signed on 10/13/2026 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:CARNELIAN VILLASFACILITY NUMBER:
306005680
ADMINISTRATOR/
DIRECTOR:		STRUVE, JINGFACILITY TYPE:
740
ADDRESS:1773 S. CARNELIAN STREETTELEPHONE:
(714) 860-4490
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 6DATE:
10/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Richard RoblesTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Caregiver(CG) Richard Robles who also has an active Administrators certificate. CG called Administrator (AD) Cherie Wood and discussed the purpose of the visit.

The facility is a single story home with six private resident bedrooms, one staff bedroom, eight bathrooms, a living room, a dining room, a family room, a kitchen, and an attached two car garage. LPA toured the facility and observed the kitchen is clean and free of vermin. The facility has a two day perishable and seven day non perishable food supply on hand. The emergency food and water was found in the pantry. All appliances were found to be operational. The knives were in a locked drawer by the oven. The medication is in a locked cabinet across from the fridge. A first aid kit was observed in a kitchen cabinet with all the required components. LPA observed a fire extinguisher charged and with a purchase date of January 2, 2026. The resident rooms had all the required components and furnishings. LPA tested the water in the bathrooms to be between 108.5 and 109.2 degrees Fahrenheit. LPA observed the bathrooms needing to be cleaned with dirt and grime in the sink and a dark rings in the toilets. The extra linens are in a closet located in the hall by the staff rooms. The garage is used for extra facility storage and a laundry room. The garage is locked and made inaccessible to residents in care with toxins and chemicals being stored. The backyard has a shaded seating area and is free of debris and obstructions. The side gates are made accessible. CG tested the carbon monoxide detector and they were found to be operational. A 20”X26” PUB 475 poster was not observed in the facility.

Continue on LIC809C

Kevin Saborit-Guasch
Hanna Fuller
DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2026
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 6
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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Document Has Been Signed on 10/13/2026 04:16 PM - It Cannot Be Edited


Created By: Hanna Fuller On 10/13/2026 at 03:51 PM
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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026

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
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Based on observation, the licensee did not comply with the section cited above in LPA observing the restrooms needing to be clean with visible dirt/grime in the toilet and sink which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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Licensee to have staff clean the facility restrooms and conduct an in service with staff regarding cleaning and send proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Hanna Fuller
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2026 04:16 PM - It Cannot Be Edited


Created By: Hanna Fuller On 10/13/2026 at 03:51 PM
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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA not observ ing a 20" X 26" PUB 475 poster int he facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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Licensee to obtain the correct size poster and send 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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Hanna Fuller
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2026 04:16 PM - It Cannot Be Edited


Created By: Hanna Fuller On 10/13/2026 at 03:51 PM
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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 2 staff not having updated 20 annual hour training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2026
Plan of Correction
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Licensee to train staff and provide LPA proof of updated training by POC due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in LPA reviewing the Emergency Disaster Plan and not observing any indication that it has been signed, reviewed or updated annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2026
Plan of Correction
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Licensee to review, update and sign the Emergency Disaster plan and send 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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Hanna Fuller
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
VISIT DATE: 10/13/2026
NARRATIVE
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LPA reviewed resident files and no discrepancies were observed. LPA reviewed staff files and 1 of 2 staff do not have updated 20 hours of annual training. LPA reviewed the emergency disaster plan and did not observe it to be updated yearly by AD. LPA reviewed medications and no discrepancies were observed. All staff present are background cleared and associated to the facility. The last fire drill was conducted on October 5, 2026.

Based on today’s inspection, deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809D, Staff records reviewed and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Hanna Fuller
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
LIC809 (FAS) - (06/04)
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