197603706-6-3-2025-28-AS-MCOA-DHAQL9-20250603121534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603706
Report Date: 06/03/2025
Date Signed: 06/03/2025 12:15:56 PM

Document Has Been Signed on 06/03/2025 12:15 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:	MPS HOME		FACILITY NUMBER:	197603706
ADMINISTRATOR/ DIRECTOR:	RICARDO BANOS		FACILITY TYPE:	740
ADDRESS:	5313 FIDLER AVE		TELEPHONE:	(562) 920-6960
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY: 4		CENSUS: 4	DATE:	06/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Maria Tavarez, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit. LPA met with Kevin Rodriguez, Caregiver, and explained the reason for the visit. Assistant Administrator, Maria Tavarez, arrived thereafter and assisted with the visit. Ricardo Banos, Administrator, was contacted telephonically and was also informed regarding the reason for the visit.

The facility is licensed to serve 4 non-ambulatory developmentally disabled elderly residents ages (60) and above. Hospice Waiver for (2) residents in place. The facility is operating within the scope of its license. Residents receive services through the Harbor Regional Center.

The facility is in a residential area of Lakewood, CA. During the visit, LPA toured the facility's indoor and outdoor environment and reviewed (4) resident and (3) staff files. Resident medication was also reviewed The facility is a single-story house which consists of: living room, dining area, kitchen, (4) resident bedrooms, (2) bathrooms, office area, activity room, laundry area in the garage, backyard/outdoor patio, and attached garage.

During today’s visit, LPA observed the following:

Facility was observed to be clean and maintained. Walkways around perimeter of facility are clear of obstructions.

Living room furniture is clean and in good repair. There is sufficient seating for residents in care. Fire place was observed to be covered and inaccessible to residents.

****Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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: MPS HOME	FACILITY NUMBER: 197603706
	VISIT DATE: 06/03/2025

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Sufficient supply of 2 day perishable and 7 day non-perishable food was observed. Food is labeled and kept within expiration limits. Pantry was observed stocked and dry food transferred to "Easy Pour" containers is dated and identified by its content. Current menu observed posted in the kitchen. Sufficient resh fruit observed in the dining area.

Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and mattress pads. There is a closet in the hallway with extra clean linen, towels, and personal hygiene items for clients. Resident bedrooms are equipped with motion sensors connected to a main dock for staff to monitor.

Two full bathrooms were inspected and were observed clean and sanitary. Showers have grab bars and anti-slip mats. The water temperature was tested in both bathrooms and measured within the required 105 - 120 degrees F.

Interconnected, combination smoke/carbon monoxide detectors were observed throughout the facility and were tested and observed to be working properly. There is one fire extinguisher located in the kitchen which was observed to be charged. Lasts fire extinguisher inspection was conducted on 3/5/25.
Drills are conduced monthly. Last fire/safety drill was conducted on 6/1/25/25.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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: MPS HOME	FACILITY NUMBER: 197603706
	VISIT DATE: 06/03/2025

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Sufficient supply of 2 day perishable and 7 day non-perishable food was observed. Food is labeled and kept within expiration limits. Current menu is posted in the kitchen. Sufficient fresh fruit observed in the dining area. Pantry was observed and "Easy Pour" containers were dated and labeled to identify contents.

Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Beds have the required linen and mattress pads. There is a closet in the hallway with extra clean linen, towels, and personal hygiene items for residents. Bedrooms are equipped with motion sensors which were tested and working properly.

Two full bathrooms were inspected and were observed clean and sanitary. Showers have grab bars and anti-slip mats in place. The water temperature was tested in both bathrooms and measured 111.3 degrees within the required 105 - 120 degrees F.

Interconnected, combination smoke/carbon monoxide detectors were observed throughout the facility and were tested and observed to be working properly. There is one fire extinguisher located in the kitchen which was observed to be charged. Lasts fire extinguisher inspection was conducted on 3/25/25. Drills are conduced monthly. Last fire/safety drill was conducted on 6/1/25. Doors leading out of the facility are equipped with alert chimes which were tested and working properly.

The front and backyard are well maintained and there are no pools or large bodies of water. There is a seating area accessible to residents, located in the backyard patio. Patio umbrella is used for shade. Patio furniture is in good repair and there is enough seating for residents.

Garage was observed clean and free of clutter. Laundry area is located in the garage. Detergents are kept locked and inaccessible to residents. Washer and dryer were observed in good repair and working during visit. Ramps, passageways and exits are free of obstruction.

****Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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: MPS HOME	FACILITY NUMBER: 197603706
	VISIT DATE: 06/03/2025

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Medication is centrally stored and locked in cabinet. Resident medication was reviewed and observed to be dispensed and documented accordingly.

Four (4) resident and (3) staff files were reviewed and contained relevant documentation.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Maria Tavarez, Assistant Administrator and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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