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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602638
Report Date: 12/29/2025
Date Signed: 12/29/2025 01:24:25 PM

Document Has Been Signed on 12/29/2025 01:24 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:D & L RESIDENTIAL CARE HOME 1FACILITY NUMBER:
198602638
ADMINISTRATOR/
DIRECTOR:		RAFAEL DIAZFACILITY TYPE:
740
ADDRESS:330 WEST CITRUS EDGE STREETTELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
12/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Noel Navarro, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced case management visit. LPA was greeted by staff and the reason for the visit was explained. Administrator Ralph Estanislao was advised telephonically but was not able to attend. The purpose of the visit was to follow up on items addressed during the Noncompliance Conference (NCC) meeting held on October 1, 2025.

The facility is licensed to serve age range 60 and over, six (6) non-ambulatory of which one (1) may be bedridden. Hospice waiver for two (2). The facility is operating within the scope of their license with five (5) non-ambulatory residents, one (1) of which is under the age of 60 and two (2) residents are on hospice. The facility is a single-story home located in a residential area of Glendora. The home consists of a kitchen, living room, dining area, two (2) bathrooms, four (4) resident bedrooms, an attached garage, front and backyards.

Upon arrival LPA observed a port-a-potty in the driveway and visible construction in the backyard. LPA asked administrator about the construction. The administrator indicated the property owner was building an addition. Staff indicated construction workers use a gate located on the side of the house to access the construction area. Construction crew does not come in the house and does not have contact with residents. LPA did not observe any construction tools or construction debris that may pose a health and safety risk to residents in care. Staff stated if residents want to go outside, they go to the front yard. CCL was not notified prior to construction. Deficiency cited.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
Document Has Been Signed on 12/29/2025 01:24 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 12/29/2025 at 10:55 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
CCR
87608(a)(3)

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
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Licensee agrees to send LPA physician's orders for bedrails for R1 and R4 by POC due date or remove bedrails. Orders for R5 were obtained at time of visit
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Based on observation and record review, the licensee did not comply with the section cited above R1, R4 and R5 did not have a order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/19/2026
Section Cited
CCR87458(c)(1)(A)

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87458 Medical Assessment (c)(1)(A) The medical assessment shall include, but not be limited to:
A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:
Communicable tuberculosis.
This requirement is not met as evidenced by:
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Licensee agrees to submit via email TB clearance for R1, R2, and R5 by POC due date
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Based on record review 3 out of 5 resident records did not contain TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638
VISIT DATE: 12/29/2025
NARRATIVE
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continued from LIC 809

LPA toured facility interior and interior was observed to be clean and free of debris and obstructions. Water temperature was checked in both resident bathrooms and tested at 109.7°F and 109.4°F, which is within the required 105°F-120°F. LPA observed four (4) out five (5) residents to have bedrails. Only one (1) of the four (4) residents had physician’s orders for bedrails in the residents’ files. Deficiency cited. Penalty assessed for repeat violation.

LPA reviewed five (5) resident files. Three (3) out of five (5) resident files did not contain record of TB clearance. Deficiency cited.

LPA reviewed three (3) staff files. S2 file did not contain a completed Health Screening and did not have TB clearance on file. Deficiency cited.

LPA reviewed MAR log. Medications are documented properly and given as prescribed.

LPA reviewed log for emergency drills. Last fire/earthquake drill was conducted 12/14/25.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Civil penalties issued for repeat violation within 12 months.

Exit interview held and a copy of the report along with appeal rights were provided to Caregiver Noel Navarro.

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

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/29/2025 01:24 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 12/29/2025 at 12:44 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
CCR
87412(a)(11)

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874129(a)(11)Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:


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Licensee agrees to submit via email a completed health screening with TB clearance for S2.
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Based on record review one (1) out of three (3) staff records, S2 staff file did not contain a completed Health Screening with TB clearance which poses a potential health and safety risk to residents in care.
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Type B
01/12/2026
Section Cited
CCR87208(a)

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87208(a)Plan of Operation. The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49…Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
This requirement is not met as evidenced by:
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Licensee will submit an updated plan of operation, advise how residents may be affected, a timeline for contruction completion and building permits for construction by POC due date.
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Based on observation construction of an additional structure in the backyard has begun without prior notification and approval from licensing, which may affect services to residents and which may pose a health and safety risk to residents in care.
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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: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


LIC809 (FAS) - (06/04)
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