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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 08/19/2025
Date Signed: 08/19/2025 03:05:28 PM

Document Has Been Signed on 08/19/2025 03:05 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:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR/
DIRECTOR:		BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 75CENSUS: 69DATE:
08/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Kenpatrick Padilla, Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by the Wellness Director, Ken Patrick Padilla, and explained the purpose of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over, hospice waiver approved for ten (10) residents and non-ambulatory to be housed on the second floor only. There are currently (69) residents residing in the facility, of which five (5) are under hospice care and (0) bedridden.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan in place.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (10) is approved, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/04/2025. LPA reviewed that the Liability insurance is in place. Fire and disaster drills were last conducted on 08/19/2025.

Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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 5
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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
VISIT DATE: 08/19/2025
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Physical Plant/Environment Safety [Cont.]: Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room. Third floor: (34) resident rooms and Laundry room. The interior and exterior physical plant was inspected. LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed Emergency Chairs at the stairways. Carbon Monoxide and Smoke detectors are interconnected and were tested annually and working properly. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random resident rooms (Rooms: 103, 113, 115, 120, 201, 205, 207 and 219) in the 2nd & 3rd floors. Water temperature readings measured between 111.3 degrees F to 119.1 degrees F within the required 105 - 120 degrees Fahrenheit.

Staffing: A total of (44) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records-Training: Seven (7) staff files were reviewed which include: Personnel Record, health screening, TB test results, Employee Rights, valid First Aid / CPR/AED Training, staff training. Executive Director’s Administrator’s certificate is valid and expires on 02/18/2027. However, based on record review, the Executive Director, Staff #2 (S2), Staff #5 (S5), and Staff #6 (S6’s) file did not have the Health Screening and TB. Test.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and have access to the facility phone.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
VISIT DATE: 08/19/2025
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Food Service: Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas.

Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. The first Aid kit was observed and has all required items.

Resident Records/Incident Reports: LPA reviewed seven (7) resident files that include the Face Sheet, Identification and Emergency Information form, Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Personal Service Assessment, Physician's Orders, Ambulatory Status, and Personal Rights.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was last updated 06/07/2024 is in place with contact numbers and at least two (2) relocation sites. LPA observed the evacuation chairs at each stairway is in place.

Residents with Special Health Needs: Four (4) residents are receiving home health services. Five (5) residents receive hospice care. Seven (7) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents’ doors.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Wellness Director, Ken Patrick Padilla.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/19/2025 03:05 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/19/2025 at 02:55 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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Executive Director, Staff #2 (S2), Staff #5 (S5), and Staff #6 (S6’s) file did not have the valid Health Screening and TB test result in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2025
Plan of Correction
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Licensee will send the Executive Director, Staff #2 (S2), Staff #5 (S5), and Staff #6 (S6’s) Health Screening and TB test result to the LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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