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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006657
Report Date: 06/23/2026
Date Signed: 06/23/2026 11:51:16 AM

Document Has Been Signed on 06/23/2026 11:51 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:CK COMMUNITY CAREFACILITY NUMBER:
306006657
ADMINISTRATOR/
DIRECTOR:		TRAN, EVANFACILITY TYPE:
740
ADDRESS:21322 ANTIGUA LANETELEPHONE:
(714) 819-0629
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
06/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Evan TranTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On June 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Evan Tran was notified via telephone and later arrived to assist with the inspection. LPA observed that Evan Tran has a valid Administrator certificate which expires on January 2, 2028.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one can be bedridden in room four, and has a hospice waiver for six. The facility is a single story home which consist of four resident bedrooms, two of which is shared, two bathrooms, a living room, a dining room, a kitchen, a sun room, a laundry room, and an attached two car garage. LPA, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, LPA observed five residents in care and two care giving staff present. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the four resident bedrooms and observed them to be clear of any hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway cabinets. LPA inspected the resident bathroom and observed it to be clean. Resident bathroom was equipped with grab bars and a non-skid floor mat. The faucet and toilet was operational. Hot water temperature measured at 117.6 degrees Fahrenheit.

LPA observed the facility has a two day perishable and a seven day non-perishable food supply in the kitchen. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet.
CONTINUED ON LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2026
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: CK COMMUNITY CARE
FACILITY NUMBER: 306006657
VISIT DATE: 06/23/2026
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LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed two fire extinguishers to be mounted in the facility which were observed to be charged and serviced as of December 3, 2025. LPA tested the wired smoke detectors and individual carbon monoxide detectors which tested operational. LPA observed the facility conducted their most recent emergency disaster drill on March 19, 2026. LPA observed the centrally stored medication to be kept in a locked closet. LPA observed there is also a first aid kit stored in the closet which has all the required components. LPA also observed the facility has a three day emergency food and water supply to be stored in the closet. LPA observed chemicals and toxins to be stored in locked cabinets located in the laundry room. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage.

LPA, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPA observed the exterior to be clear of any obstructions or hazards. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates of the facility to be self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed the residents' medication and medication administration records. LPA reviewed three staff files. LPA observed that three staff did not complete the required forty hours of initial training. LPA observed that the facility did not have any documented training on file for Staff #1 (S1). LPA also observed that Staff #2 (S2) and Staff #3 (S3) only had seventeen documented hours of training on file. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Administrator Evan Tran and he was also advised regarding the facility's annual fee balance. A copy of the report and appeal rights were provided at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/23/2026 11:51 AM - It Cannot Be Edited


Created By: Brandon Lopez On 06/23/2026 at 11:40 AM
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: CK COMMUNITY CARE
FACILITY NUMBER: 306006657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that three staff did not complete the required forty hours of initial training. LPA observed that the facility did not have any documented training on file for Staff #1. LPA also observed that Staff #2 (S2) and Staff #3 (S3) only had seventeen documented hours of training on file.
POC Due Date: 07/07/2026
Plan of Correction
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The Administrator stated that he will have the three staff complete the required forty hours of initial training. The Administrator agreed to provide LPA proof of completed training for the three staff via email or fax 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2026


LIC809 (FAS) - (06/04)
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