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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603473
Report Date: 08/25/2025
Date Signed: 08/25/2025 03:05:15 PM

Document Has Been Signed on 08/25/2025 03:05 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:ST. CECILIA'S SENIOR HOME IIIFACILITY NUMBER:
198603473
ADMINISTRATOR/
DIRECTOR:		POORTEN, JOSIAH VANDERFACILITY TYPE:
740
ADDRESS:260 N. LONE HILLTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 5DATE:
08/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Glenda Precillas - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:30 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) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Glenda Precillas and explained the reason for the visit. Licensee arrived shortly after.

The facility is licensed to serve 6 residents age 60 and over of which 6 may be non-ambulatory with a hospice waiver for 6. The facility is located in a residential area and consist of a single home with (4) resident bedrooms, (3) bathrooms, a living room, a dining room, a kitchen, a family room, an attached garage/laundry, a front yard, and a back yard.

The following domains were reviewed during this visit:
Infection Control: Facility maintains a copy of the infection control plan. Staff #2-4's medical assessments did not have results for TB test.
Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't any residents under hospice care, or bedridden. A current liability insurance was observed and a copy was obtained.
Physical Plant/Environmental Safety: LPA toured the facility with Glenda Precillas and observed the following. Facility was observed clean and in good repair. Living room, dining room, and family room were observed with furniture in good repair. Living room has a covered fireplace. Kitchen was observed clean. Cleaning supplies and sharps are maintained locked under the sink. Refrigerator/freezer and pantry were observed. Medication cabinet is located in family room. Four (4) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Half bed rails were observed in residents' beds and physician's orders were on each residents' file. Three (3) bathrooms were observed in good repair and clean
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2025
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 5
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 5
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: ST. CECILIA'S SENIOR HOME III
FACILITY NUMBER: 198603473
VISIT DATE: 08/25/2025
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
Water temperature was tested in each bathroom sink and tested at 105.3 degrees F., which is within the required 105-120 degrees F. Oxygen tanks were observed in bedroom #3, no smoking sign was not observed. A fire extinguisher was observed. Carbon Monoxide/Smoke detectors were tested and are in working condition. Laundry area was observed in good repair. Two large bodies of water were observed, a pool and a pond. The pool has a 5ft fence surrounding it and the pond has a screen covering it. Passageways were clear of obstructions.
Staffing: Administrator certificate was reviewed for Josiah Poorten #7020881740 exp. date: 11/11/25. CPR/First aid training was observed for staff. Staff is on duty during the night shift.
Personnel Records/Staff Training: LPA reviewed 5 staff files. Files were available for review. Files include; health screening, background clearance, personnel record, and training for each staff. Two staff were interviewed.
Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the family room.
Planned Activities: Facility provides activities such as puzzles, books, board games, music entertainer.
Food Services: LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the garage. Kitchen was observed clean and free of pest.
Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in locked medication closet. LPA reviewed medication for 5 residents.
Resident Records/Incident Reports: LPA reviewed 5 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal. Two resident were interviewed.
Disaster Preparedness: LPA reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 7/14/25. Emergency drills are conducted quarterly, last emergency drill was conducted on 7/14/25.
Residents with Special Health Needs: Facility is not serving residents with Special Health Needs.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Glenda Precillas and a copy of this report, LIC 809D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/25/2025 03:05 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/25/2025 at 02:57 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: ST. CECILIA'S SENIOR HOME III
FACILITY NUMBER: 198603473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 in 4 out of 5 staff, staff #2-4 did not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2025
Plan of Correction
1
2
3
4
Administrator will obtain a copy of TB test clearance and submit it to the department by POC due date 9/1/25.

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:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5