<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006580
Report Date: 09/01/2026
Date Signed: 09/11/2026 09:25:14 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2026 09:25 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 ACHILLESFACILITY NUMBER:
306006580
ADMINISTRATOR/
DIRECTOR:		GABRIEL, JEHLA ROSEFACILITY TYPE:
740
ADDRESS:598 PIERPONT DRTELEPHONE:
(424) 270-4452
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
09/01/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jehla Gabriel, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 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 and Licensing Program Managers (LPMs) Alfonso Iniguez and Sheila Marie-Santos made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA and LPMs were greeted and granted entry by staff. During today’s visit, LPAs met with Jehla Gabriel, Administrator. The Administrator has a valid administrator certificate through August 12, 2027. The facility has active liability insurance from February 5, 2026 to February 5, 2027.

The facility is licensed for six non- ambulatory clients, one may be bedridden and a hospice waiver for four. The facility currently has a census of four in care. The facility is a two story home consisting of six client bedrooms, one staff bedroom upstairs, four client bathrooms, a kitchen, dining area, living room, and an attached garage. LPA observed the PUB 475 “See Something Say Something” poster posted in the hallway.

During today’s visit, LPA and LPMs 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 110.7 to 116.4 degrees F. 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. One out of four residents had medication left unlocked in their night stand, a citation is being issued. The facility’s last fire drill was conducted on August 21, 2026. Fire extinguishers were charged and operable.

Continued on the LIC 809C
Alfonso Iniguez
Taylor Simerly
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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 4
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)
Page: 2 of 4
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 ACHILLES
FACILITY NUMBER: 306006580
VISIT DATE: 09/01/2026
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
26
27
28
29
30
31
32
LPA and LPMs toured the exterior and observed a shaded seating area for client use, no hazards or obstacles were observed. The side gates was operational.

LPA and LPMs 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 supply in the pantry and water supply located in the garage. Cleaning supplies were locked and stored away from food.

Medication storage and administration practices were reviewed. LPA reviewed the centrally stored medications for all four clients and discrepancies were found. The First Aid Kit had the required elements.

LPA reviewed two staff files and all four client files. No discrepancies were noted in the staff or client files.

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

Based on observations and record reviews conducted during today’s inspection, The following deficiencies are being cited per Title 22 Division 8 of the California Code of Regulations. An exit interview was conducted with Jehla Gabriel, Administrator and a copy of this report was emailed 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: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/11/2026 09:25 AM - It Cannot Be Edited


Created By: Taylor Simerly On 09/01/2026 at 03:11 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: CARE ACHILLES
FACILITY NUMBER: 306006580

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2026
Section Cited
CCR
87465(h)(2)

1
2
3
4
5
6
7
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will submit a plan of future ways to prevent medication being left out and provide a training to all staff by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in which R3 had unlocked medication in their night stand which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4