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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:43:47 PM

Document Has Been Signed on 12/15/2025 04:43 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ASUNCION BOARD & CAREFACILITY NUMBER:
198600290
ADMINISTRATOR/
DIRECTOR:		ROSEMARIE A. ZIMMERFACILITY TYPE:
740
ADDRESS:1636 S. RAMA DRIVETELEPHONE:
(626) 338-0772
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 6CENSUS: 3DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Adelaida Asuncion LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with Licensee Adelaida Asuncion. LPA explained the purpose of the visit. During the visit, the CARE tool was used. The facility is licensed to serve Dementia residents, ages 60 and above, approved for two (2) non-ambulatory and four (4) ambulatory residents. Currently, there is no hospice resident in placement.
The facility is a single-story house located in a residential neighborhood. It consists of five (5) bedrooms including three (3) resident bedrooms, one (1) staff room, one (1) room for family member; three (3) bathrooms, kitchen, dining room, living room, and detached garage. Facility was toured, staff/residents files were reviewed. Residents medications were reviewed. No pools and bodies of water on the premises. All residents' bedrooms and bathrooms were inspected. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. The common areas are clean and have the required furniture. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested and was measured within Title 22 Regulation guidelines. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space.
The kitchen was inspected. LPA observed that kitchen equipment are in working condition. LPA observed sufficient supply of perishable and non-perishable foods. There is additional food in the refrigerators located in the garage. Adequate linen and personal hygiene supplies was observed. Auditory alarm devices to monitor exits were operable.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASUNCION BOARD & CARE
FACILITY NUMBER: 198600290
VISIT DATE: 12/15/2025
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 Knives and sharps are locked in the kitchen and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguisher observed in the dining room and fully charged. Laundry area was observed in the covered patio between the house and garage. Laundry detergents were observed locked next to the washer and dryer and in the garage. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet; resident and staff records are stored in a locked room and both inaccessible to residents. First Aid kit was fully stocked with current manual. LPA reviewed 3 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Two staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPA reviewed residents' medications. Medications are documented properly and given as prescribed.

No deficiencies were found during this visit. Exit interview was conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
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