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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607893
Report Date: 07/03/2025
Date Signed: 07/03/2025 12:37:31 PM

Document Has Been Signed on 07/03/2025 12:37 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:C-H #6 RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
197607893
ADMINISTRATOR/
DIRECTOR:		FISHER-ASHLEY, ADLEANFACILITY TYPE:
740
ADDRESS:8726 DORIAN STTELEPHONE:
(562) 633-3612
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 4DATE:
07/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:DSP Yeneka DavisTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA’S) Christian Gutierrez, and Gaby Castro conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA’s met Caregiver Yeneka Davis at approximately 9:38 AM and explained reason for visit. Administrator Ashley Fisher arrived shortly.

The facility is licensed to serve up to (4) non-ambulatory residents ages 60 and older. The facility is a single-story home located in a residential area. A tour of the facility includes living room, dining room, kitchen, (3) client bedrooms, 1 staff room, 2 bathrooms, laundry room, attached garage with extra refrigerator and large freezer, front yard, and backyard. There are currently four (4) ambulatory residents serviced by South Central Los Angeles Regional Center.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. Smoke detectors were observed in each room and throughout facility. Carbon monoxide device was not working at time of visit. The facility has one (1) fire extinguisher that is fully charged in laundry room. Cleaning supplies, sharp objects, and toxic substances are inaccessible locked in laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. LPAs did not observe a sufficient supply of 2 days perishable food. LPAs did observe a sufficient supply of 7 days non-perishable foods in the kitchen. There are no firearms or weapons stored at the facility The resident bathrooms have the required grabs bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The common areas include the living room and dining area are clean and have the required furniture. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents in back yard. Passageways and exits are free of obstruction.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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Document Has Been Signed on 07/03/2025 12:37 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/03/2025 at 12:09 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: C-H #6 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 facility did not have a sufficient supply of 2 day non perishable food for residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
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Administrator went shopping for fresh fruits, vegetables, lunch meats at time of visit. POC cleared at time of visit.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 12:37 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/03/2025 at 12:09 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: C-H #6 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 carbon monoxide did not have working batteries, and all doors audio devices were inoperable at time of visit.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Administrator replaced battieres at time of visit deficiency cleared at time of visit. Administrator will repair devices and send LPA Video by POC due date.
Type B
Section Cited
CCR
87219(j)
Planned Activities
(j) The licensee shall provide sufficient equipment and supplies to meet the requirements of this section, including access to variety of reading materials. Special equipment and supplies necessary to reasonably accommodate the individual physical persons and mental needs of residents shall be provided as appropriate.

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 facility did not have and supplies for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Administrator will purchase games, books, and crafts for residents and send LPA pictures 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 12:37 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/03/2025 at 12:09 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: C-H #6 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:

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 in one (1) out of four (4) did not have required paperwork in folder which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Administrator will send R4 addmision agreement, Medical assesment, appraisel needs and service, and pre admissions agreement by POC due date by email.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: C-H #6 RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 197607893
VISIT DATE: 07/03/2025
NARRATIVE
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Three (3) out of three (3) staff files reviewed and included Criminal clearance record, and health screening with TB, and CPR/First Aid certificates. Three (3) out of four (4) resident files were reviewed and included physicians report, TB clearance, and appraisal needs and service plans. R4 is missing admission agreement, medical assessment, pre- admission appraisal, appraisal needs and service plan, and consent forms. Last fire/earthquake drill was conducted in June of 2025. Infectious control plan was reviewed. One (1) staff, and three (3) residents were interviewed. Resident medications were reviewed, and no discrepancies found. Medications are centrally stored.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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