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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602212
Report Date: 10/06/2025
Date Signed: 10/06/2025 01:23:29 PM

Document Has Been Signed on 10/06/2025 01:23 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:BUNGALOWFACILITY NUMBER:
198602212
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, CARINAFACILITY TYPE:
740
ADDRESS:1314 WOODBURY ROADTELEPHONE:
(626) 296-6977
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: DATE:
10/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by caregiver Lourdes Cruz and the purpose of the visit was explained. Administrator Linda Morales arrived shortly after to assist with the tour.

The facility is licensed to serve six (6) residents age range 60 and over of which four (4) may be non-ambulatory and of which one (1) may be bedridden. The home is located in a residential neighborhood in Pasadena and consists of a living room, dining area, kitchen, five (5) resident bedrooms, one (1) full bathroom and two (2) half bathrooms, front yard and patio.

The front yard is well maintained and there are no pools or large bodies of water. There is a covered patio providing a shaded seating area located in the patio with sufficient seating for residents in care. Passageways and exits are free of obstructions.

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

The water temperature was tested in bathroom #1 and measured 105.8 degrees F, which is within the required 105 degrees F - 120 degrees F. Bathroom #2 water temperature measured 114.4 degrees F and bathroom #3 measured 106.8 degrees F. LPA observed grab bars and non-skid mats the bathrooms.

Continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2025
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 10/06/2025 01:23 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 10/06/2025 at 12:51 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: BUNGALOW
FACILITY NUMBER: 198602212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in LPA observed the facility to have 1 resident (R6) on hospice, but no approved Hospice Waiver on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2025
Plan of Correction
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Administrator agrees to review Title 22 Regulation Section 87632 & 87633, and submit a Hospice Waiver with all required information to the CCL office for review and approval. The waiver request is due by POC due date.

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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2025


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: BUNGALOW
FACILITY NUMBER: 198602212
VISIT DATE: 10/06/2025
NARRATIVE
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continued from LIC 809

Resident bedrooms have the required furniture and have sufficient closet and storage space. Resident beds have the required linen and the linen is in good repair.

Hallway cabinet contained PPE supplies, surplus clean linens.

Combination smoke and carbon monoxide detector located throughout the home, were tested and are operable. LPA observed a fire extinguisher located in the kitchen last serviced March 31, 2025. Emergency drills conducted monthly, last drill was 09/11/25.

Kitchen was observed to be clean and free of pests. Kitchen appliances are clean and were operating at the time of the visit. Sharps secured under the kitchen sink and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Dining area observed clean with sufficient seating for residents in care.

Centrally stored medication is located in a locked cabinet in the dining area. Medications are documented properly and given as prescribed.

Six (6) resident and four (4) staff files were reviewed. R6 file did not contain physician’s report/medical assessment with TB clearance. Licensee was able to produce at time of visit. Technical violation noted.

R6 receiving hospice care services, facility does not have a hospice waiver. Deficiency cited.

Licensee provided with information to submit for change of administrator.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report along with appeal rights were provided to the Administrator Linda Morales.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2025
LIC809 (FAS) - (06/04)
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