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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608124
Report Date: 03/13/2026
Date Signed: 03/13/2026 05:14:27 PM

Document Has Been Signed on 03/13/2026 05:14 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:NARRA TREE, INC. - JEFFREY HOMEFACILITY NUMBER:
197608124
ADMINISTRATOR/
DIRECTOR:		MARIA TERESA SANTOSFACILITY TYPE:
740
ADDRESS:18414 JEFFREY AVENUETELEPHONE:
(562) 865-4394
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
03/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:House Manager- MadalisayTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced annual inspection of the facility. LPA arrived and met House Manager Madalisay. The purpose of today’s visit was explained. The facility is licensed to serve 6 elderly , non-ambulatory residents ages 60 and above.

The facility is a single-story home located in a residential area in Cerritos, Ca. A tour of the facility includes: living room, kitchen, dining area, 4 bedrooms (2 double and 2 single), 2 bathrooms (1 bathroom located in client room), front yard, back yard, attached garage with laundry.

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

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility and a designated Infection Control Lead.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required current liability insurance.

Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and walkways and hallways are free of debris and obstruction. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The required furnishings, light and bed linens were observed. There were extra linens and towels present. The backyard is free of debris/hazards and the outdoor and indoor passageways are free of obstruction. No bodies of water were observed at the facility. A shaded table and chairs were present to allow the residents to enjoy the outdoors. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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: NARRA TREE, INC. - JEFFREY HOME
FACILITY NUMBER: 197608124
VISIT DATE: 03/13/2026
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 was measured in both bathrooms and was measured within Title 22 requirements of 105 degrees F- 120 degrees F for both bathrooms.

All storage areas for cleaning solutions, toxins, knives, sharps and hazardous items are kept locked and are inaccessible to residents. Smoke detectors are present in each resident room and the living room. All were observed to be operable. A carbon monoxide detector was present and operable. There was a fire extinguisher present that was observed to be fully charged.

Staffing: There appears to be sufficient staffing at all times in the facility. The night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records-Training: Staff files are kept in a secure location. LPA reviewed 5 staff files. Files were reviewed for Criminal Record Clearance, Health Screening, Current First Aid and CPR as well as initial and ongoing training for care of the Elderly. Administrator’s certificate is current.

Resident Records Resident records were kept in secure location and were reviewed for the following documents - Pre-admission appraisal/Appraisal Needs & Services Plan, Medical Consent, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 resident files and no issues were observed.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. All the required postings were observed.

Planned Activities: Facility offers activities like coloring and chair exercises and a central TV viewing area for residents to enjoy together. There is an outdoor furnished patio area available for the residents. Residents are taken outside for walks.

Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was stored separately from cleaners, toxins and poisons. Appliances were observed to be operable and able to properly store and prepare food. A deficiency was noted. See 809-D.

Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
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: NARRA TREE, INC. - JEFFREY HOME
FACILITY NUMBER: 197608124
VISIT DATE: 03/13/2026
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Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. LPA reviewed 2 residents’ medications and there were no issues observed.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency food and water were observed. A full First Aid kit and Manual were available. Last disaster drill was conducted on 03/03/26.

Residents with Special Health Needs: Residents at this facility that require the use of bed rails have the required doctor’s approval. Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during today’s visit.

Exit interview was held with House Manager Madalisay and a copy of this Licensing report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
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