198602955-11-13-2025-28-AS-BGOZ-DNE2VC-20251113164343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602955
Report Date: 11/13/2025
Date Signed: 11/13/2025 04:43:53 PM

Document Has Been Signed on 11/13/2025 04:43 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:	CARINDALE RESIDENTIAL CARE		FACILITY NUMBER:	198602955
ADMINISTRATOR/ DIRECTOR:	NARVAEZ, JANET		FACILITY TYPE:	740
ADDRESS:	1342 S. BARRANCA		TELEPHONE:	(626) 426-1369
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY: 6		CENSUS: 6	DATE:	11/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:49 PM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	04:50 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) Blanca Gonzalez conducted an unannounced required annual visit. LPA was met by caregiver Jessica Torres and the purpose of the visit was explained. Administrator Angela Gavilanes was advised telephonically. The facility is a two-story home located in a residential area of Glendora. It is licensed to serve residents age range 60 and over, six (6) non-ambulatory of which one (1) may be bedridden and has a hospice waiver approved for 2. The home consists of a living room, kitchen, dining room, (6) resident bedrooms, (1) staff room located upstairs, (2) bathrooms, (1) staff/visitor bathroom, laundry area, a shaded patio in the backyard with seating, and a detached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: The front and backyard are well maintained and there are no pools or large bodies of water. The backyard does contain a fenced in waterfall/water feature. Passageways and exits are free of obstructions. Carbon monoxide and smoke detectors were observed in resident bedrooms and are operable. There five (5) fire extinguishers located throughout the facility and were last serviced 10/02/25. Emergency drills conducted quarterly, last drill was 10/06/2025. continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

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 4

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 4

Document Has Been Signed on 11/13/2025 04:43 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 11/13/2025 at 03:55 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: CARINDALE RESIDENTIAL CARE	FACILITY NUMBER: 198602955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) 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: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in1 out of 6 resident facility files, R2's medical assessment, did not contain TB clearance which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2025
	Plan of Correction
1 2 3 4	Licensee agrees to submit proof of TB clearance, via email, for R2 by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 11/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

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: CARINDALE RESIDENTIAL CARE	FACILITY NUMBER: 198602955
	VISIT DATE: 11/13/2025

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
26
27
28
29
30
31
32

continued from LIC809

Kitchen appliances are clean and were operating at the time of the visit. Sharps are secured in a kitchen drawer and are inaccessible to residents. Kitchen area was observed to be clean and free of litter, rodents, vermin and insects. The food supplies were observed to be the required 2-day perishables and 7-day non-perishables. Cleaning supplies, disinfectants and toxins are secured in a locked hall closet, inaccessible to residents in care. Dining room and living room are clean and free of obstructions and have sufficient seating for residents in care. Fireplace located in the living room was inaccessible with a covered screen. The facility has cameras in common areas. According to staff, cameras do not record, they are only used for surveillance.

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 closet contained clean linens and towels. Water temperature tested in all three (3) bathroom and measured within the required 105°-120°F.

Washing machine and dryer were clean and operable at the time of visit.

Medications are centrally stored in a locked filing cabinet in the kitchen. Medications are documented properly and given as prescribed.

Six (6) resident and four (4) staff files were reviewed and were observed to contain required documentation. R2 facility file and medical assessment did not contain TB clearance. Deficiency cited.

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 Caregiver Jessica Torres.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4