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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603478
Report Date: 08/08/2025
Date Signed: 08/08/2025 04:24:52 PM

Document Has Been Signed on 08/08/2025 04:24 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. DANIEL'S SENIOR CARE, INC.FACILITY NUMBER:
198603478
ADMINISTRATOR/
DIRECTOR:		DANIEL DAVIS JR.FACILITY TYPE:
740
ADDRESS:2403 N. INDIAN HILL BLVDTELEPHONE:
(909) 971-7083
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 3DATE:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Deborah DavisTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Required Annual Visit. LPA met with Licensee Deborah Davis, Administrator Daniel Davis, and explained the purpose of the visit. The Residential Care Facility for the Elderly is licensed to serve six (6) Non-Ambulatory residents ages 60 and above. Facility has an approved Hospice Waiver to retain/accept six (6) residents of which two (2) may be Bedridden. Currently, there are three (3) residents in placement, one (1) Hospice, zero (0) Bedridden (0) Exceptions, and one (1) receiving Home Health Care. LPA observed (3) residents at the time of this visit. LPA Madyun requested copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020) were provided.

Physical Plant/Environment Safety: A tour of the single-story facility began at approximately 10:35 am that included rooms: one (1) private staff bedroom with an exiting door, one (1) staff/visitors bathroom, one (1) staff lounge (located in garaged area), five (5) bedrooms with an exiting door, one (1) resident bathroom, a living room, a dining area, a family room, and a kitchen. All resident bedrooms have the required furniture for privacy, comfort, and safety. LPA observed the carbon monoxide detectors, fire sprinklers, and inter-connected smoke detectors throughout the hallways and rooms. LPA observed required auditory devices on exits of each room. Three (3) Fire extinguishers were fully charged and located in the kitchen, garage, and directly outside the staff office and last inspected on 6/7/25. First-aid kit was fully stocked with a first-aid manual locked securely in the staff office. LPA did observe the Emergency Disaster Plan last reviewed and updated May 2025.



Front Yard: Was clean and well maintained without any hazards.

Continued LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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: ST. DANIEL'S SENIOR CARE, INC.
FACILITY NUMBER: 198603478
VISIT DATE: 08/08/2025
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Kitchen: LPA observed a sufficient number of perishables for two (2) days, and a seven (7) day supply of non-perishables. LPA observed knives and sharps locked away secured in the kitchen cabinet to be inaccessible to three (3) out of six (6) residents in care. LPA Madyun observed several bottles of cleaning solutions and disinfectants located in the bottom kitchen cabinet to be locked away secure and inaccessible to three (3) out of six (6) residents in care. Water temperature measured at 113.7 degrees F, which is within the required 105-120 degrees F under Title 22 regulations. Kitchen appliances were observed to be clean and in working order.

Family room/Living room/Dining Area: Family room was observed with ample seating and lighting. Dining Area was observed to be clean and contained one table with ample seating. The living room was observed with ample seating and lighting.

Linen Closet: Contained sufficient linens, towels, and hygiene products.

Bathrooms: Bathrooms are clean and operational with grab bars, and skid resistance floors. Water temperatures measured at 113.5-114.8 degrees F, which is within the required 105-120 degrees F under Title 22 regulations. Both bathrooms were observed to be clean and in good condition.

Centrally Stored Medications: LPA observed the medication for all residents being locked and securely stored in the staff office.

Backyard: LPA observed multiple shaded seating areas. No large bodies of water were observed.

Emergency Drills: LPA observed the smoke alarms tested and a Fire Drill log documenting the last fire drill conducted 7/10/25.

Staff Personnel Files: LPA reviewed files for (3) staff.

Resident Files: LPA reviewed files for (3) residents and medication logs.

Liability Insurance & Infection Control Plan: Licensee has current Liability Insurance. Annual fees are paid in full and current. Infection Control Plan was last reviewed and updated May 2025.

Exit interview was conducted with Licensee Deborah Davis and a copy of this report and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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