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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607962
Report Date: 05/15/2026
Date Signed: 05/15/2026 02:55:42 PM

Document Has Been Signed on 05/15/2026 02:55 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:QUEEN OF THE ANGELS ASSISTED LIVING INC.FACILITY NUMBER:
197607962
ADMINISTRATOR/
DIRECTOR:		TERRY & MARY MCGEEFACILITY TYPE:
740
ADDRESS:420 S. MANNINGTON PLACETELEPHONE:
(626) 430-7702
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 5DATE:
05/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Barbara Boiston - House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Joel Basillo and Cathlyn Eroza, Caregivers and explained the purpose of the visit. The administrator, Terry McGenn was called to inform of the visit. At 10:25am, Barbara Boiston, House Manager arrived and assisted LPA. The facility is approved to serve residents age range 60 and above. Facility fire cleared for (2) ambulatory and (4) non ambulatory residents age 60 and above. Approved to accept or retain up to (6) residents on hospice. 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 maintained. Staff are trained in the proper use of all required PPEs prior to being around residents. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.


Operational Requirements: Facility has working signal systems in exit points. The facility has a dementia care plan to accept or retain residents with dementia. Staff have the required training to provide special care to dementia residents. Staff cannot provide a copy of the liability insurance during the visit.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (6) bedrooms, one of which is a staff bedroom, (3) bathrooms, living room with fireplace, family room with a fireplace, kitchen, dining room, laundry area and backyard with patio area. There are currently (5) residents, 60 years and older residing in the facility, (1) is under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed the large sliding door in the staff bedroom is impassable, completely blocked by stacks of boxes. LPA observed that the living room is used for sleeping which was confirmed by a staff member. The fireplaces are adequately screened and inaccessible to residents. Backyard was inspected and has a swimming pool surrounded by a locked gate. There are (2) fire extinguishers in the facility which were serviced on 04/15/2026. Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit *****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2026
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: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962
VISIT DATE: 05/15/2026
NARRATIVE
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Staffing: A total of (8) caregivers including the Administrator provide care and supervision to the residents. One (1) staff provides night supervision and can assist in caring for residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses and certificate is valid through 04/08/2027.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Facility provides initial and ongoing training for staff.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities.
Residents are encouraged to participate in a variety of planned activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. LPA observed uncovered left over food in the refrigerator and food containers were not labeled. LPA also observed the preparation plastic bowls were stored along with cleaning supplies and other chemicals in a kitchen cabinet under the sink.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents. Facility did not have an up to date prescribed and PRN medication list for the residents. Staff did not properly document the medications administered to the resident on the medication administration record (MAR).
Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. Fire drill conducted monthly, last fire drill was on 04/02/2026.
Residents with SHN: (1) resident is under hospice care and one resident on oxygen. Physician orders for 1/2 bed rails were reviewed on the residents' files. Staff did not have training in the operation of the oxygen equipment.

Deficiencies cited and Technical advisories issued. Exit interview and a copy of this report along with the appeal rights were provided to Barbara Boiston, House Manager.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/15/2026 02:55 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/15/2026 at 01:53 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: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in that the living room is used for sleeping, confirmed by a staff member which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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Administrator/House Manager will ensure that the living room will not be used as a sleeping room by any staff member. Administrator/House Manager will send a signed self certification that they have read, reviewed and understood Title 22 regs, 87307 to CCLD/LPA by POC due date.
Type B
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in that the staff did not complete the 12-hour dementia training as required which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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House Manager agreed to train all staff members and submit a signed in service training log indicating the topics discussed to CCL/LPA 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/15/2026 02:55 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/15/2026 at 01:53 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: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that the staff did not properly document the medications administered to the resident on the medication administration record (MAR) which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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House Manager to re-train staff on properly documenting medication administration records (MARs) for all residents and submit a copy of the signed in service training log to CCLD/LPA by POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that the facility did not have an up to date prescribed and PRN medication list from the residents' physicians which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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House Manager/Administrator to obtain an up to date medication list of prescribed and PRN medications from the residents' physicians and send a copy to CCLD/LPA 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2026


LIC809 (FAS) - (06/04)
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