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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 07/29/2025
Date Signed: 08/01/2025 02:06:23 PM

Document Has Been Signed on 08/01/2025 02:06 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: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: 2DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:04 AM
MET WITH:Yenny Indrawati- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:09 PM
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Licensing Program Analyst (LPA) Vaid conducted an unannounced required annual inspection. LPA met with Caregiver Luz Macalisang and explained the purpose of today’s visit. Administrator Yenny Indrawati was notified and arrived shortly after.
This facility is licensed to serve three (3) non-ambulatory and three (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. Facility may retain no more than five (5) hospice residents. There are two (2) residents receiving assisted care. The facility is a single-story dwelling located in a residential neighborhood.
LPA utilized the CARE tools for the visit today and observed the following:

Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.
Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof of liability insurance, and will email copy to LPA.
The 1-story facility consist of the following: 5 Resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, and backyard area.
Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons were observed to be inaccessible to residents. Carbon monoxide detectors and smoke alarms in hallways operational. LPA inspected two (2) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in bathrooms were measured within 105 – 120 degrees F., observed grab bars near toilets. Nonskid mats and shower chair were observed. Sharps and knives are inaccessible to residents. Laundry machine working properly. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Fire extinguisher is fully charged. Continued on 809C..........
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 07/29/2025
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Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff is participating in continuous trainings. CPR and 1st aid.

Personnel Records Training: Staff files are maintained at the facility. LPA observed required annual training, CPR and First Aid for two staff personnel records reviewed. Observed TB testing, Health screening, fingerprint clearance for two (2) out of the two (2) personnel records reviewed.
Food Service: LPA Vaid observe sufficient supply of nonperishable for one week and perishables for 2 days. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).
Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MARs) log to document medications given. The facility provides incidental medical services.
Resident Records/Incident Reports: LPA reviewed two (2)resident files, files are maintained at the facility.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. LPA Vaid observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Emergency drills(fire and earthquake) were last conducted 7/19/25.

Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed a facility land line.
Residents with Special Needs: Staff does not use manual restrictive devices.

No Deficiencies were observed on todays' visit.
Copy of report given to Administrator Yenny Indrawati.

Licensee will forward to case carry LPA Gonzalez pertinent documents regarding the ADU addition to the facility. Updated LIC 200, physical plant sketch. From city of Glendora: Occupancy class code, permits and pertinent documents received from city of Glendora planning department.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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