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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 01/30/2026
Date Signed: 01/30/2026 05:36:17 PM

Document Has Been Signed on 01/30/2026 05:36 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR/
DIRECTOR:		YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 5DATE:
01/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jeffrey Yang, AdministrtorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tao and Mallett conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with Staff#1 upon arrival and Administrator Jeffrey Yang join shortly after. LPAs explained the reason for the visit to Administrator. Facility annual fees are current. Liability insurance coverage is current which covers from 06/28/25 – 06/28/26.

This facility is licensed to serve six (6) non-ambulatory residents, age 60 and above and have one (1) hospice waiver approved. Dementia waiver is in place.

Today’s inspection consisted of applying CARE tool, conducting physical plant, reviewing staff/residents records, checking residents’ food supply/medication, and interviewing staff/residents.

Infection Control:

Facility maintains an infection control plan was on file. Staff were observed practicing safe hand washing. Hand sanitizing was observed throughout. Hygiene supply and sanitizing materials were observed in each bathroom and changing station.

(-continued on LIC 809C-)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 01/30/2026
NARRATIVE
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Physical Plant & Environmental Safety:

The facility consists of an administrator office room, kitchen, living room, family room, dining room, six (6) resident bedrooms, one (1) staff bedroom, three (3) resident bathrooms, one (1) staff bathroom, a detached garage, a front yard, and backyard. Physical plant was conducted and observed the facility is in good repair indoor and outdoor. Facility is operating within capacity. A swimming pool was observed in the backyard which is secured with a 5ft fence with a locked gate and not accessible to the residents. Cleaning supplies and sharp materials were observed locked and inaccessible to clients. Outdoor space is furnished, shaded, and accessible to residents. Passageways and exit areas were observed free of obstructions. Restrooms were observed clean. Water temperature was tested within 107 - 108.7 degrees F., which is within the required 105-120 degrees F per Title 22 requirement.

Staff/ Residents Records review:

Administrator certificate is current, and the expiration date is 12/01/27. Staff and residents’ records were reviewed but files were incomplete. See LIC 809 D for citation details.

Food Service:

The kitchen was clean. The required two (2) days of perishable and seven (7) days of nonperishable were observed and stored separately from toxic/cleaning supply.

(-Continued on LIC 809C-)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 01/30/2026
NARRATIVE
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Health-Related Services:

Medications were reviewed. Medications are centralized stored and inaccessible to the residents. First aid kit was reviewed.

Incidental Medical Services:

Facility does not currently serve any residents with restricted health conditions.

Disaster Preparedness:

Emergency Disaster Plan LIC610E was observed and last reviewed on 2/07/25. A contingency plan was observed. Last emergency drill was conducted on 01/30/26.

Exit:

Deficiencies were noted during this visit and cited per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Administrator Jeffrey and LIC 809s and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2026 05:36 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/30/2026 at 04:57 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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: 1) all staff records are incomplete, either missing LIC 501, 503...etc. 2) Staff#1 and Staff# 2 records were not available for review during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agreed to ensure staff records are complete by POC due date
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

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 as all residents files are missing admission agreement, and the other files were incomplete, either missing TB test result, Personal rights, concent forms, phyisican presciption...etc, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agreed to ensure residents records are complete 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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/30/2026 05:36 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/30/2026 at 04:58 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times.

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:
1) the left, back burner of the stove in the kitchen was not working, 2) the paint on the ceiling at room #4 doorway is peeling, 3) the bathroom cabinet in room #3 has an opening (missing a drawer), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agreed to fix the back burner to make it operatable, repaint the celiing at room #4 doorway, and repair the bathroom cabinet drawer to cover the opening by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2026


LIC809 (FAS) - (06/04)
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