<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602639
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:28:47 PM

Document Has Been Signed on 03/11/2025 02:28 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:D & L RESIDENTIAL CARE HOME 2FACILITY NUMBER:
198602639
ADMINISTRATOR/
DIRECTOR:		RAFAEL DIAZFACILITY TYPE:
740
ADDRESS:1036 S. BARRANCA AVENUETELEPHONE:
5627747167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
03/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:19 PM
MET WITH:Rita HerreraTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nicol Wesley conducted a Case Management inspection as a result of the complaint visit 28-AS-20250304103541 conducted 03/11/2025.

During the complaint visit, LPA Wesley observed space heaters in the living room and kitchen area, and asked if the heater works. LPA Wesley was told no. LPA also observed trash cans with no lids and during the complaint investigation there was no clearance for staff #1.

The following deficiencies are cited according to the California, code of regulations, title 22.
appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 2
Document Has Been Signed on 03/11/2025 02:28 PM - It Cannot Be Edited


Created By: Nicol Wesley On 03/11/2025 at 01:46 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 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2025
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or...

1
2
3
4
5
6
7
The facility shall make sure all staff all staff are fingerprint cleared and associated prior to working in a facility.
Per the administrator Rita Herrera, staff Bong Narcisco Jr. is no longer working in the facilty.
8
9
10
11
12
13
14
This evidence was not met as required..during the meeting with the residents and administrator it appears that staff Bong Narcisco Jr. was not cleared/associated to the facility and posed a health and safety threat to the residents in care.
8
9
10
11
12
13
14


**Immediated $100 civll Penalty issued**
Type B
04/10/2025
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
Maintenance and Operations
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
The Administrator shall have the centralized heater repaired and send proof of service to Attn Nicol Wesley, 323 980 4912 by POC due date 04/10/2025
8
9
10
11
12
13
14
This item was not met as required: When LPA arrived to the facility she observced space heaters in the living room dinning room of the faclity which poses a health and safety risk to the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2