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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006342
Report Date: 10/01/2026
Date Signed: 10/01/2026 05:37:22 PM

Document Has Been Signed on 10/01/2026 05:37 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:MARIGOLD BOARD AND CAREFACILITY NUMBER:
306006342
ADMINISTRATOR/
DIRECTOR:		TRANAE QUATICE GATLINFACILITY TYPE:
740
ADDRESS:8601 SAN ROMOLO WAYTELEPHONE:
(657) 214-2241
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 5DATE:
10/01/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Tranae GatlinTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:


The facility is a single level structure and licensed for six nonambulatory residents. As of today, the facility has five residents, and four were present during the annual inspection. Bedrooms: There’s a total of four bedrooms, and all four bedrooms are for the residents in care. All resident bedroom’s were clean and in compliance with regulation guidelines. Bathroom: There’s a total of two bathrooms. One bathroom is for staff; however, available to residents when needed. No cleaning items were observed in the main resident bathroom. Hot water measured at 129.6 degrees F. Kitchen: Kitchen was clean and organized. All four burners were operational on the gas stove. Sharps are locked in the medication cabinet. Cleaning items are kept locked in a cabinet below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen.

Resident & Staff Files: Resident and staff files are locked in filing cabinets near the dining room.
File Review: 4 of 5 resident files were reviewed during the visit, and three staff files were reviewed.


Medications/First-Aid Kit: Resident medications are stored in a locked medication cabinet in the kitchen. A first aid kit was observed in a closet in the main hallway.
Medication Review: 4 of 5 resident medications were reviewed during the visit.

Continued on LIC809C
Kevin Saborit-Guasch
Jerome Haley
DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2026
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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342
VISIT DATE: 10/01/2026
NARRATIVE
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Linens Supplies: Additional linen was observed in a closet in the main hallway.
Laundry: A laundry area equipped with a washer and dryer was observed in the garage.

Garage Area: The garage is primarily used as a storage area. An emergency supply of water and food was observed. Incontinent care supplies were observed, an additional refrigerator with an additional food supply was also observed.

Backyard/Exterior: The backyard is clean and walkways are free of obstruction. A table and chairs was observed under a shaded patio area. There’s a shed used to store incontinent care supplies and arts and crafts items.
Bodies of Water: None.

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.

Fire Extinguisher: Fire extinguishers were observed mounted on a wall in the main hallway and garage.

An emergency evacuation drill: Was conducted May 13, 2026.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:


Several facility postings are posted are available for review on the wall at the entrance of the facility.

Additional Comments: Emergency food and water was observed during the inspection. Facility contact information was reviewed.

Deficiencies are being cited and technical violations are being issued as a result of today’s inspection.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026
LIC809 (FAS) - (06/04)
Page: 10 of 10
Document Has Been Signed on 10/01/2026 05:37 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/01/2026 at 04:42 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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above as hot water measured at 129.6 degrees F which poses an immediate health and safety or personal risk to persons in care.
POC Due Date: 10/02/2026
Plan of Correction
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Administrator Gatlin will send LPA Haley a video recording of the hotwater temperature meeting regulation guidelines by the close of business on the POC due date.
Type A
Section Cited
HSC
1569.625(c)(4)
Other Provisions
(c) The training shall include, but not be limited to, all of the following: (4) Policies and procedures regarding medications.

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. 3 of 3 staff record reviews did not have annual medication training, which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/05/2026
Plan of Correction
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Administrator Gatlin has ensured staff has registered for medication training to be provided by Career Smart Learning. The 8 hour training certificates for all staff will be email to LPA no later than Monday (10.5) at 11:00am.
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:
Jerome Haley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2026


LIC809 (FAS) - (06/04)
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