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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608094
Report Date: 10/18/2025
Date Signed: 10/18/2025 11:14:01 AM

Document Has Been Signed on 10/18/2025 11:14 AM - 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:NARRA TREE INC/IBEX HOMEFACILITY NUMBER:
197608094
ADMINISTRATOR/
DIRECTOR:		MA. TERESA SANTOSFACILITY TYPE:
740
ADDRESS:18918 IBEX AVENUETELEPHONE:
(562) 860-1599
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 6CENSUS: 4DATE:
10/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:House MGR Ma LazoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Hazzell Tuason at approximately 9:00 AM and explained reason for visit. House Manager Ma Dalisay Lazo arrived shortly.

This home is licensed to serve six developmentally disabled, elderly residents 60 years of age and older, (4) Bedridden and (2) non-Ambulatory. The facility has 24/7 awake staff. The facility prefers to serve developmentally disable residents. There were (3) clients in care during the time of this visit. Facility is vendor with the Harbor Regional Center. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the living room, and it is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in laundry room. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. SEE 809C

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2025
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: NARRA TREE INC/IBEX HOME
FACILITY NUMBER: 197608094
VISIT DATE: 10/18/2025
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/ First aid training, and health screening with TB. Four (4) resident files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in September of 2025. Infectious control plan was reviewed. One (1) staff and (2) residents was interviewed. Four (4) resident medications were reviewed. Medications are centrally stored and locked MAR log is used.

No deficiency was observed during today’s visit. Exit interview was conducted with House Manager and a copy of report was provided.

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

DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
LIC809 (FAS) - (06/04)
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