<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604439
Report Date: 06/17/2025
Date Signed: 06/17/2025 12:33:47 PM

Document Has Been Signed on 06/17/2025 12:33 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:CON CARINO INC.FACILITY NUMBER:
197604439
ADMINISTRATOR/
DIRECTOR:
GUTIERREZ, CHRISFACILITY TYPE:
740
ADDRESS:1260 N. SIERRA BONITA AVETELEPHONE:
(626) 794-2105
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
06/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Dolores Del Carmen Ortiz, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:45 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 Analysts (LPA), Mayra Cota, conducted an unannounced Required 1 year visit. LPA was granted entrance and met with Dolores Del Caremen Ortiz, Caregiver, and the purpose of the visit was explained. Stacy Santana Lopez, Manager, arrived shortly thereafter. There are four (4) residents currently living in the facility.

The facility is licensed to serve (6) non-ambulatory residents ages (60) and above. Hospice waiver approved for (1) resident. The facility is operating within the scope of its licence. The facility is in a residential area of Pasadena and it consists of living room, dining room, kitchen, five resident bedrooms, (1) full and (1) half bathroom, laundry/supply room and front and back yard.

During today's visit, the following was observed:

  • Facility is clean and walkways, ramps and staircases are free of debris and obstructions. Furniture throughout the facility was observed in good repair. There is sufficient seating in the living and dining room for residents. 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. There is a closet in the hallway with extra clean linen and towels for residents.
  • Kitchen appliances were clean and were operating at the time of visit. Sharps are locked in a kitchen cabinet and are inaccessible to residents. Cleaning supplies and toxins are locked in a cabinet under kitchen sink. Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and an additional emergency food supply was observed in the Laundry. Food is labeled and kept within expiration limits. An over flow refrigerator is kept in the laundry room and was observed stocked with extra food.

***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: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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)
Page: 2 of 3
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: CON CARINO INC.
FACILITY NUMBER: 197604439
VISIT DATE: 06/17/2025
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
26
27
28
29
30
31
32
  • Both bathrooms were inspected and were observed clean and sanitary. Shower in main bathroom has grab-bars and anti-slip mats. The water temperature was tested in both bathrooms and measured at 113.5 degrees F in bathroom 1- and 112.9 degrees F in bathroom 2, which is within the required 105 - 120 degrees F. Sufficient personal hygiene supplies for residents were observed in laundry room for residents in care.

  • The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to residents, located in the front and backyard. Patio furniture observed clean and in good repair. Gardens are maintained and passageways and exits are free of obstruction. Laundry room in the back of the house was observed free of clutter and washers and dryers were observed to be operable during visit. Basement entry way observed in the backyard was locked and inaccessible to residents.

  • Smoke detectors were observed throughout the facility and were tested and observed to be working properly. Carbon monoxide detector located in the hallway was also tested and was also observed to be working properly. Two fire extinguisher, one located by the kitchen and one in the laundry room were observed to be charged and were last inspected on 5/31/25.. Last fire/safety drill was conducted on 6/2/25. Exit doors are equipped with door chimes and were tested and working properly. Fireplace in the living room is covered and is inaccessible to residents.

  • Four resident and five staff files were reviewed and contained required documentation. Files were observed locked appropriately. Medication observed centrally stored, locked and inaccessible to residents. Medication review was also conducted and medication was observed to be administered and documented accordingly per physician's orders.


Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed and noted during today's visit. Exit interview held with Stacy Santana Lopez, Manager, 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: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3