306006915-7-21-2026-22-AS-EBEY-DW7PWJ-20260721114048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006915
Report Date: 07/21/2026
Date Signed: 07/21/2026 11:41:06 AM

Document Has Been Signed on 07/21/2026 11:41 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:	VAO SWEET HOME CARE		FACILITY NUMBER:	306006915
ADMINISTRATOR/ DIRECTOR:	DAO, JEANNIE		FACILITY TYPE:	740
ADDRESS:	15311 CASCADE LANE		TELEPHONE:	(714) 373-1218
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 6		CENSUS: 5	DATE:	07/21/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Jeannie Dao - Applicant/Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	On July 21, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived announced for the purpose of conducting the Pre-Licensing visit for an Initial Application. LPA conducted the visit with Applicant/Administrator Jeannie Dao. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on February 5, 2026, for age range 60 and older, with Fire Clearance approved for five (5) non-ambulatory residents of which one (1) may be Bedridden in Bedroom #2, with a Hospice waiver for six (6). LPA toured the facility's indoor and outdoor physical plant with Applicant/Administrator Jeannie Dao and the following were observed: Structure: The facility is a single-story property in a residential neighborhood comprised of six (6) resident bedrooms, two (2) full bathrooms, two (2) staff bedrooms, one (1) staff 1/2 bathroom, and an attached two car garage. The common areas include the living room, dining area, kitchen, and backyard with a covered seating area. Telephone Number: The facility currently has a land line with the number (714)373-1218. CONTINUE TO LIC809-C ....

Kevin Saborit-Guasch
Eboni Bentley
	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: VAO SWEET HOME CARE	FACILITY NUMBER: 306006915
	VISIT DATE: 07/21/2026

NARRATIVE

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Emergency Phone Numbers/Exit Plan:
Posted in the entry way.

Postings:
The See Something, Say Something (PUB475) was posted in the correct size and all other required posting
were available in the entry way.

Food Service and Menu:
Supply of seven-day non-perishable and two-day perishables were observed in the kitchen. The emergency
food and water supply were also available. LPA observed the Food Menu and Activity Schedule posted.

Smoke and Carbon Monoxide Detectors:
The smoke detectors and carbon monoxide alert systems were tested and found operational.

Fire Extinguishers:
There were two (2) fire extinguishers mounted, fully charged, and last serviced on February 23, 2026.

Fire Clearance:
Approved on February 25, 2026, for five (5) non-ambulatory and one (1) Bedridden resident in Bedroom #2.

Signal System:
The facility has a signal system for residents.

Bedrooms:
The resident bedrooms had all required components and accommodate the residents’ furnishings. All rooms
and closets contained space for residents’ personal items and belongings.

CONTINUE TO LIC809-C ....

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: VAO SWEET HOME CARE	FACILITY NUMBER: 306006915
	VISIT DATE: 07/21/2026

NARRATIVE

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Bathrooms:
Bathrooms were clean with grab bars available and slip mats were present.

Water Temperature:
The water temperature in the resident bathrooms measured between 106.3 and 118.0 degrees Fahrenheit.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies for resident use were fully stocked.

Appliances:
Stove burners, microwave, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records were maintained on site and reviewed.

Medication:
Medication were found stored and secure in a closet in the hallway.

Reading Material, Games, Equipment, & Materials:
Games and activities were available.

Sharps and Toxins:
Sharps will be secure in drawer in the kitchen and inaccessible. Cleaning supplies and toxins were locked
under the sink.

First Aid Kit, & Manual:
The First Aid Kit was checked and contains all the required elements.

CONTINUE TO LIC809-C ..

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: VAO SWEET HOME CARE	FACILITY NUMBER: 306006915
	VISIT DATE: 07/21/2026

NARRATIVE

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Liability Insurance:
Facility does not have liability insurance for the new facility, however a proposal for liability insurance protection was observed. Component III was reviewed with the applicant, fulfilling the requirements for existing facilities.

On today's visit, all items reviewed during this inspection are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Administrator Jeannie Dao, and a copy of this report was provided at
the time of this visit.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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