198204276-4-22-2025-28-AS-MCOA-DFYQSH-20250422122533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204276
Report Date: 04/22/2025
Date Signed: 04/22/2025 12:26:09 PM

Document Has Been Signed on 04/22/2025 12:26 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:	MPS HOME II		FACILITY NUMBER:	198204276
ADMINISTRATOR/ DIRECTOR:	MARIA TAVAREZ		FACILITY TYPE:	740
ADDRESS:	5404 PEARCE AVENUE		TELEPHONE:	(562) 572-9931
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY: 4		CENSUS: 4	DATE:	04/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:44 AM
MET WITH:	Belma Fernandez, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mayra Cota conducted an unannounced required annual visit. LPA met with Belma Fernandez, Caregiver, and explained the reason for the visit. Administrator, Maria Tavarez, arrived thereafter and assisted with the visit. The facility is licensed to serve 4 non-ambulatory elderly residents, ages 60 and over, with a Hospice waiver for 2 residents. The facility is operating within the scope of its license. Clients receive services through the Harbor Regional Center. The facility is a single-story home located in a residential area of Lakewood, CA. LPA and Administrator toured the home and inspected the living room, dining area, kitchen, 4 resident bedrooms, 2 resident bathrooms, 1 staff bedroom with private bathroom, laundry area, attached garage, front yard and back yard. During today’s visit, LPA observed the following: Inside the home: Living room and dining area are clean and furniture is in good repair. Both areas have enough seating for residents. A fireplace was observed and is covered appropriately. Kitchen counter tops and meal preparation surfaces were observed clean and free of clutter. Kitchen appliances were observed in operable condition during time of visit. ***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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 04/22/2025 12:26 PM - It Cannot Be Edited

Created By: Mayra Cota On 04/22/2025 at 11:05 AM

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: MPS HOME II	FACILITY NUMBER: 198204276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having several dry and canned food beyond the "best if used by" date in the kitchen pantry. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2025
	Plan of Correction
1 2 3 4	Licensee will ensure, food in the pantry is regularly checked by staff and logged. Licensee will check pantry every week to ensure food is used before "best if used by" date. Licensee will provide a photo of replenished pantry with purchased fresh dry and canned goods and photo of the log for one week.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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: MPS HOME II	FACILITY NUMBER: 198204276
	VISIT DATE: 04/22/2025

NARRATIVE

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Sharps/knives are kept locked in a kitchen cabinet. Cleaning supplies and toxins are also kept locked and inaccessible to residents in care.
Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and additional food is kept in an overflow refrigerator in the garage..
Several dry and canned food items were observed to be kept beyond the "best if used by" date in the kitchen pantry.
Dry food containers were observed without an expiration label in the pantry.
Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and mattress pads.
Extra resident mattress pads, bed linen, absorbency pads (Chux), and towels are kept in a closet.
Resident bathrooms were inspected and were observed clean. Safety mats were observed and showers are equipped with safety grab bars.
The water temperature was tested in both resident bathrooms and measured at 109.2 degrees F in bathroom 1- and 109.5 degrees F in bathroom 2 which is within the required 105 - 120 degrees F.
Personal hygiene products are readily available for residents in care.

Outdoor environment:

The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to clients, located in the backyard.
Passageways and exits are free of obstruction.
Attached garage was inspected and is used for storage.
Garden area is well maintained and gardening tools were observed locked at the time of visit.

Medication and Record Review:

Resident medications are centrally stored and locked in medication cabinet. Medication was observed to be administered per physician's orders and documented accordingly on MAR logs.
Four resident and five staff records were reviewed. Records reviewed have all required documents.

***Continues in LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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: MPS HOME II	FACILITY NUMBER: 198204276
	VISIT DATE: 04/22/2025

NARRATIVE

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Disaster Preparedness:

Combination smoke and carbon monoxide detectors were observed throughout the facility and were tested and working properly at the time of visit.
Two fire extinguishers were inspected and were observed charged. Both were last serviced on 3/5/25.
Extra emergency supplies like a flashlight and a food supply are kept in the garage.
Facility is equipped with a backup generator.
First Aid kit and manual are kept readily available for use.
Ramps and stair cases are free of obstructions.

A Technical Advisory is being issued and a Deficiency is being cited (See LIC 809-D) per California Code of Regulations, Title 22, and California Health and Safety Code

Exit interview was conducted with the Assistant Maria Tavarez. A copy of the report, appeal rights was issued.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC809 (FAS) - (06/04)

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