198603494-1-21-2026-28-AS-SVAD-DQJU92-20260121142224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603494
Report Date: 01/21/2026
Date Signed: 01/21/2026 02:22:33 PM

Document Has Been Signed on 01/21/2026 02:22 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:	ASSISTED LIVING & WELLNESS - HOLLY		FACILITY NUMBER:	198603494
ADMINISTRATOR/ DIRECTOR:	SANDOVAL, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1740 HOLLY AVE		TELEPHONE:	(626) 317-5178
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY: 6		CENSUS: 6	DATE:	01/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	LVN, Margaret Grancich		TIME VISIT/ INSPECTION COMPLETED:	02:30 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) Vaid conducted an unannounced annual inspection visit. LPA Vaid met Kristina Brown who allowed entry into facility. LVN, Margaret Grancich was notified and arrived shortly after to assist with the visit. The facility is licensed to serve six (6) non-ambulatory residents, ages 60 and above, of which one (1) may be bedridden. Bedroom#6 is approved for bedridden. The facility has an approved Hospice Waiver (for six (6) residents) and a Dementia Care program. Administrator certificate is pending, and the expiration date is 07/22/2025. During the visit, the CARE tool was used, staff /residents were interviewed, staff/residents’ records were reviewed, physical plant was conducted, food supply was reviewed, and medications were reviewed. The facility is a single-family residence located in a neighborhood, consisting of six (6) bedrooms, three (3) full bathrooms, 1 half bath (only has a toilet and a sink), kitchen, dining room, sunroom, den, nook, laundry room, office, and living room with a TV. No pools and bodies of water on the premises. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was measured at 108.2, 106.9, 107.9 and 114.6 degrees Fahrenheit for 4 bathrooms which were within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Auditory alarm devices to monitor exits were operable. Sufficient supply of perishable and nonperishable foods is observed. Smoke and carbon monoxide detectors are dual/hardwired and operable. Fire extinguishers’ last service is 02/03/2025 and are fully charged. Medication is centrally stored in a locked cabinet and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Continued on 809C...............

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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 3

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 3

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: ASSISTED LIVING & WELLNESS - HOLLY	FACILITY NUMBER: 198603494
	VISIT DATE: 01/21/2026

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

Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. Posted Liability Insurance expired 10/22/2025. Residents files and staff files were observed and are completed. Medications is stored in locked cabinet and are inaccessible to the residents. Staff and residents files were observed and are inaccessible to residents. Cleaning products are locked and inaccessible to residents.

No deficiencies were observed during the facility inspection. An exit interview was conducted. This report was discussed and provided to Margaret Grancich, LVN.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3