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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:40:23 AM

Document Has Been Signed on 09/04/2024 10:40 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:VILLA VICTORIAFACILITY NUMBER:
198603439
ADMINISTRATOR/
DIRECTOR:		INDRAWATI, YENNYFACILITY TYPE:
740
ADDRESS:1640 S. GLENDORA AVETELEPHONE:
(626) 888-7811
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
09/04/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Yenny Indrawati and Sugi WongTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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An Informal Conference was conducted today in the Monterey Park Regional Office. The purpose of this informal conference meeting is to discuss the high number of citations that were issued during the annual inspection dated July 19, 2024 . Present in the meeting is Licensing Program Manager David Sicairos, Licensing Program Analyst Kimberly Ramirez, Licensing Program Analyst Daniel Konishi along with facility representatives Yenny Indrawati, Administrator and Sugi Wong, Licensee. The informal conference process was explained during this meeting.

Issues discussed during the meeting were:
  • High number of deficiencies that were cited during the Annual Inspection on July 19, 2024. Total 11 citations which were seven (7) Type A and four (4) Type B citations were issued.
  • POC Visit dated 07/23/2024 in which three (3) Type A citations were issued.

The facility has stated they will do the following to achieve continued and substantial compliance:
  • 1 Non-Ambulatory resident moved out, facility currently has 3 Non-Ambulatory residents which is within the approved facility Fire Clearance.
  • Licensee/Administrator discussed citations with facility staff and will ensure to meet Title 22 Regulations moving forward.
  • Facility will continue to work with the City in order to obtain required permit for Fire Clearance update.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies issued following the meeting. Exit interview held and a copy of the report was provided
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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