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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601665
Report Date: 11/25/2025
Date Signed: 12/04/2025 05:25:20 PM

Document Has Been Signed on 12/04/2025 05:25 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:ELEGANT CARE INC.FACILITY NUMBER:
198601665
ADMINISTRATOR/
DIRECTOR:		TAIWO TOYIN ODUNOLAFACILITY TYPE:
740
ADDRESS:834 E. 74TH ST.TELEPHONE:
(323) 821-1601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 3DATE:
11/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Taiwo OdunolaTIME VISIT/
INSPECTION COMPLETED:
05:19 PM
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“***This amended report supersedes report dated 11/25/2025; it was created to correct LIC 809C narrative information. All other aspects of the report remain in effect.

Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Required Annual Visit on 11/25/25 using the CARE Inspection tool. LPA was met by House Manager Ford Hunt and explained the purpose of the visit. At approximately 9:18 AM, House Manager began in assisting LPA with a tour of the facility and Administrator Taiwo Odunola arrived shortly after during the facility tour. The facility is a single-story house located in a residential neighborhood. The facility is fire clearance approved to serve a capacity of six (6) non-ambulatory of which one (1) may be bedridden and approved hospice waiver for two (2) clients.

During the required annual visit, LPA Madyun observed the following:



Four (4) residents’ rooms in which two (2) beds are vacant, one and half (1 1/2) bathrooms, living room/dinning area, kitchen, laundry area, and front yard. All residents’ bedrooms have the required furniture for privacy, comfort, and safety. Additional bedding supplies and grooming supplies were observed in the hallway cabinets securely locked. Bedrooms #2 had an exit door. Shared bathroom observed to be clean and in good repair with required grab bars and skid mat. Water temperature measured within the range of 105-120 degrees Fahrenheit

Physical Plant & Environmental Safety: LPA observed an updated and revised Infection Control Plan and Emergency Disaster Plan. Last documented emergency drill conducted on 10/20/25. First Aid kit observed and (1) Fire Extinguisher were observed and last checked on 11/04/25. Carbon monoxide detector and smoke detectors located throughout facility. LPA Madyun observed facility sketches with exits and emergency exits routes posted.

*****See LIC 809C*****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665
VISIT DATE: 11/25/2025
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Food Service: LPA Madyun observed the emergency food supply in kitchen cabinet. LPA observed more than enough of 2 days perishable and 7 days non- perishable food for resident's in care. Knives, sharps or other items that could pose a danger to resident's, were observed to be inaccessible. The kitchen water temperature measured within the range of 105-120 degrees Fahrenheit

Staffing/Personnel Files: Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. LPA observed four (4) of four (4) staff files. Due to time constraints LPA will return for a continuation visit for staff file reviews and conduct staff interviews.



Client Records/Centrally Stored Medications: The medications are centrally stored in the medication cabinet securely locked inaccessible to resident's. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA observed three (3) of three (3) resident files. Due to time constraints LPA will return at a later date and time for a continuation visit for resident file reviews, medication logs, and resident interviews.

Due to time constraint LPA will return a later date and time for a continuation visit. Per Title 22 Regulations deficiencies were observed please see LIC 809D. Exit interview conducted with Taiwo Odunola and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/25/2025 05:19 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 11/25/2025 at 04:45 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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in three (3) of three (3) resident's, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Licensee contacted plumber and scheduled emergency appointment for fixture. Licensee will provide receipts and keep LPA updated on process and completion of fixtures.
Type B
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

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 for one (1) of three (3) resident's, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Licensee contacted Associate Director of Department of Health Services and will provide copy of Non-Treating Providers Authorization and Disclosure form for resident.
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:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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