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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603193
Report Date: 10/18/2025
Date Signed: 10/18/2025 11:54:05 AM

Document Has Been Signed on 10/18/2025 11:54 AM - 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:CERRITOS ASSISTED LIVINGFACILITY NUMBER:
198603193
ADMINISTRATOR/
DIRECTOR:		SANTA ANA, OSVALDOFACILITY TYPE:
740
ADDRESS:18511 KAMSTRA AVENUETELEPHONE:
(562) 637-3392
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 6DATE:
10/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:58 AM
MET WITH:Runette Catibog, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 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), Mayra Cota, conducted an unannounced annual visit today. LPA met with Emma Peteza, Caregiver and the reason for the visit was explained. Runette Catibog, Assistant Administrator, arrived thereafter and continued to facilitate the visit.

The facility is licensed to serve adults age range 60 and over; approved for (6) non-ambulatory, of which (1) may be bed-ridden and approved Hospice waiver for (2). The facility is operating within the scope of its license. The facility is in a residential area of Cerritos. The single-story home consists of living room, dining area, kitchen, (3) shared resident bedrooms, (1) staff room, (2) full bathrooms, front and backyard/patio area and attached garage/laundry area.

During today’s visit, LPA toured the home and observed the following:

Facility was observed clean inside and out. Walkways, passages and exists are free of debris and obstructions. Living room and dining area have sufficient seating for residents and furniture is in good repair. Kitchen appliances were observed clean and operable. Facility has a sufficient 2-day perishable and 7-day non-perishable supply of food which is kept labeled and properly stored. Sharps/knives and cleaning supplies are kept locked in a kitchen cabinet under the sink and in are inaccessible to residents. Bedrooms were observed clean; however, Resident 1’s bed has a half bed rail which has not been ordered by physician. Both bathrooms were also observed clean and sanitary. Water temperature was tested in both bathrooms and measured at 118.3 and 118.7 degrees F, which is within compliance range.

***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2025
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
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: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193
VISIT DATE: 10/18/2025
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
The front and backyard are well maintained, and backyard has a shaded patio area and patio furniture is in good repair. Garage is kept clean and detergents and other toxins are kept locked. Laundry appliances are in good repair and were observed to be working properly. No pools or bodies of water observed.

During visit, (6) resident and (4) staff files were reviewed. Resident files contain admission agreements, Physician Reports, medical/functional assessments, Appraisals/Needs and Services Plans, TB clearance, personal rights and consent forms. Staff files contain up to date First Aid/CPR certification, health screenings, criminal background clearances and training documentation.

Resident medication was reviewed and found to be administered according to physicians’ orders and documented accordingly. Medication is centrally stored, locked and inaccessible to clients. Facility keeps PPE supplies in the garage. Emergency and Disaster Plan (LIC 610-D) was reviewed and is up to date. Facility conducts safety/fire drills quarterly. Last drill was conducted on 10/13/25 with staff and resident participation. Facility has a fire extinguisher in the dining room and was observed charged and operable. Fire extinguisher was last serviced on 6/24/25. Combination smoke and carbon monoxide detectors were tested and were working properly.

During today’s visit, a deficiency is noted and citation issued, per California Code of Regulations, Title 22, and California Health and Safety Code. Exit interview was conducted with Runette Catibog, Assistant Administrator, and a copy of the report and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/18/2025 11:54 AM - It Cannot Be Edited


Created By: Mayra Cota On 10/18/2025 at 11:09 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: CERRITOS ASSISTED LIVING
FACILITY NUMBER: 198603193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(A)
(a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident…Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in [1] out of [6] resident #1 bed has a half rail which does not have a physician order and resident #1 is not on Hospice, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2025
Plan of Correction
1
2
3
4
Administrator/Licensee will send LPA a plan indicating the request made to R1's physician for the half rails by POC due date 10/19/25. Licensee will send LPA, proof of physician order for half hand rail for R1's bed once it is approved.
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:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4