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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601953
Report Date: 01/02/2026
Date Signed: 01/02/2026 04:06:10 PM

Document Has Been Signed on 01/02/2026 04:06 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:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR/
DIRECTOR:		CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY: 106CENSUS: 89DATE:
01/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Daniel Orozco, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA met with Daniel Orozco, Executive Director and explained the purpose of the visit. The facility is licensed to serve (106) non-ambulatory residents of which (16) may be bedridden. Facility may retain up to (20) hospice residents and cleared for delayed egress.

On today's date, LPA inspected the eight (8) domains including: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

Infection Control: The facility has Infection Control Plan in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date.

Operational Requirements: Infection Control and Dementia plans are in place. Valid Liability insurance is in place. Fire and disaster drills were last conducted on 12/13/2025. Care and supervision to meet the residents’ needs was observed. Special equipment and supplies to meet the residents with special needs were observed.

Physical Plant/Environment Safety: The Facility is two (2)-story building located in Sierra Madre, CA. A tour of the facility included: 1st floor (assisted living units with private bath), 42 resident units, large dining room, private dining room, kitchen, bistro, library, cinema, laundry room, multiple staff offices, medication/nurse station, two (2) activity rooms, an elevator, public restrooms and two (2) courtyards/patios.

[Continue in LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2026
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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 01/02/2026
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 2nd floor: (memory care units with private bath – two (2) sections “Haven”-late-stage memory care and “Connections”-mild to moderate memory care), 25 units each with private bath; each side of memory care had their own dining area, kitchenette, activity area, living room and patio. The facility has a shaded area for residents in the outdoor patio/courtyard area for activity purposes. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The facility has central air/heating, call buttons in each unit and emergency sprinkler system throughout. The facility has central air and heating accommodations. The fire extinguishers were observed to be fully charged and in compliance. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA observed two (2) fireplaces that are closed and inaccessible to residents. LPA toured ten (10) random resident rooms and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system was tested in various locations and is operable. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured at ten resident’s bathroom at random which measured from 106.8 degrees F to 113.7 degrees F which is within the required 105 degrees F to 120 degrees F.

Residents Rights-Information: The facility has the following posters posted on each floor: Residents Rights, PUB475 Complaint Poster, and Ombudsman. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone.

Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Outdoor area is properly shaded for residents’ activity purposes.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incidental Medical & Dental: LPA reviewed ten (10) residents centrally stored medications with no issues. Medications were reviewed containing 30-day supply of medications. Centrally stored medications are kept in a safe and locked place not accessible to residents in care. Medications are given according to Physician directions. First aid kit is maintained. Medical and dental transportation is provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 01/02/2026
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Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. The last drill was conducted on 12/13/2025.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.***

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to the Executive Director, Daniel Orozco.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2026
LIC809 (FAS) - (06/04)
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