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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 04/28/2026
Date Signed: 04/28/2026 05:21:59 PM

Document Has Been Signed on 04/28/2026 05:21 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:VINE RESIDENCEFACILITY NUMBER:
198603317
ADMINISTRATOR/
DIRECTOR:		LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:1405 E. VINE AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 5DATE:
04/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Lorraine Lopez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Vanessa Godina Chinchilla, Care giver and explained the purpose of the visit. Shortly after, administrator Lorraine Lopez arrived to assist LPA. The facility is licensed to serve age range 60 and over, (6) ambulatory of which (5) may be non ambulatory and (1) may be bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The required cleaning and disinfection activities are performed. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements.
Physical Plant & Environment Safety: This facility is a single story home consists of (6) resident bedrooms, (3) bathrooms, (2) living rooms, family room, kitchen, dining area, attached garage and backyard. Resident bedrooms were toured and have sufficient storage space and lighting. Knives, cleaning solutions and disinfectants are locked. The smoke detectors and carbon monoxide detectors are operable. Laundry washing machine and drying machine is in the garage. There are (3) fireplaces adequately screened and covered with a plexiglass, (2) in the living room and one in the family room. All the appliances in the kitchen are working properly. The sharp knives and utensils are stored and locked in the kitchen drawer. Cleaning supplies and chemicals are stored and inaccessible to residents. There are cameras located in the common areas. No security window bars installed. Facility has working telephone service. Water temperature readings are within the required 105 - 120 degrees Fahrenheit. Indoor and outdoor passageways were kept free of any obstruction. Backyard was inspected and has (2) sitting areas with outdoor furniture. There is a swimming pool that is locked and gated with a fence.
Operational Requirements: The Infection Control Plan has been added to the Plan. Liability Insurance
policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is
valid, expires on 08/01/2026. There are (2) fire extinguishers that are fully charged, last serviced on 04/17/2026. The outdoor activity area in the backyard provides a shaded area and furnished for outdoor use.*****Refer to LIC 809C for the continuation of this report.*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2026
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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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: VINE RESIDENCE
FACILITY NUMBER: 198603317
VISIT DATE: 04/28/2026
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Due to time constraints, LPA will return at a later date for a continuation visit. LPA will complete the remaining domains: Staffing, Personal Records-Training, Resident Rights-Information, Planned Activities, Food Service, Incidental M & D, Resident Records-Incident Reports, Disaster Preparedness, Residents with SHN.

Exit Interview conducted and a copy of the report was provided to the Administrator, Lorraine Lopez.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC809 (FAS) - (06/04)
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