374604957-10-6-2026-08-AS-AGOH-DYDUDH-20260929152933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604957
Report Date: 09/29/2026
Date Signed: 10/06/2026 02:16:47 PM

Document Has Been Signed on 10/06/2026 02:16 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	KERN COURT SENIOR LIVING		FACILITY NUMBER:	374604957
ADMINISTRATOR/ DIRECTOR:	HERMINA SARAPAT		FACILITY TYPE:	740
ADDRESS:	19 KERN CT		TELEPHONE:	(858) 284-9114
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 6	DATE:	09/29/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Caregivers Lorina Espineli and Paul Pagulong. Administrator Herminia Sarapat		TIME VISIT/ INSPECTION COMPLETED:	03:35 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) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Lorina Espineli, who granted LPA entry. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Additionally, the facility is approved for two (2) hospice waivers. During today’s inspection there were six (6) residents in care, with two (2) currently on hospice. Note, LPA did step out for lunch from 12:15-1:15pm. LPA and Caregiver Paul Pagulong toured the interior and exterior of the facility and inspected each room. Administrator Herminia Sarapat arrived halfway through and joined LPA and Caregiver Pagulong for the remainder of the tour. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Two out of three tested taps accessible to clients were out of compliant range (105-120F): Common hall sink by the front door was at 107.1F, the bathroom sink of the dual occupancy bedroom tested at 130.3F, and another hall restroom sink tested at 120.4F. Staff immediately readjusted the water heater and LPA later re-tested those taps and they were confirmed to be within compliant range. They re-tested at 102.4F, 99F, and 99.3F, respectively. One Type A deficiency was cited and details are noted on the attached LIC 809-D page. [Continued on LIC 809-C]

Sabel Martinez
Arian Golbakhsh
	DATE: 09/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: KERN COURT SENIOR LIVING	FACILITY NUMBER: 374604957
	VISIT DATE: 09/29/2026

NARRATIVE

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[Continued from LIC 809]

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored and of variety. Opened food items in the fridge and freezer were dated. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care.

No toxic chemicals or poisons were accessible to clients. LPA noted that chemicals in the laundry room were double locked. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregiver Pagulong, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for September 2026. Last staff emergency drill was conducted 9/1/26 for the topics of fire and earthquake. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed one (1) staff and one (1) client, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

One (1) deficiency was cited during the inspection. An exit interview was conducted with Administrator Sarapat to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2026 02:16 PM - It Cannot Be Edited

Created By: Arian Golbakhsh On 09/29/2026 at 02:52 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: KERN COURT SENIOR LIVING	FACILITY NUMBER: 374604957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2026

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in ensuring hot water temperatures at taps accessible to residents were within the compliant range, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/30/2026
	Plan of Correction
1 2 3 4	Staff immediatley adjusted the water heater and brought temperatures under 120F. Licensee will further adjust the water heater to ensure hot water is within the compliant range. Licensee will take daily water temperatures at multiple taps for a period of 7 days and submit the log to LPA by 10/9/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026

LIC809 (FAS) - (06/04)

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