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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603532
Report Date: 04/01/2025
Date Signed: 04/01/2025 01:18:24 PM

Document Has Been Signed on 04/01/2025 01:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHALET TERRACE SENIOR LIVINGFACILITY NUMBER:
198603532
ADMINISTRATOR/
DIRECTOR:		PALOMINO, AMANDAFACILITY TYPE:
740
ADDRESS:1064 CHALET TERRACETELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 6DATE:
04/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Amanda Palomino, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:26 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required 1-year Visit on 04/01/2025. LPA was met by Staff Karla Pablo Damian and explained the purpose of the visit. Administrator Amanda Palomino arrived later to assist with the visit. Vannesa Hinojosa was also present and assisted with the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4). Two (2) out of the six (6) residents in care are currently on hospice care.

LPA OBSERVATIONS: The facility is a single-story dwelling located on in a residential neighborhood and consists of three (3) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, detached garage, front yard, and backyard. LPA Lopez observed auditory device on entry of door to be operational, sliding door and exits.

Physical Plant:

Front Yard: Is well maintained and no hazards were observed during visit.

Kitchen: LPA Lopez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Lopez observed knives and sharps located in kitchen cabinet, to be inaccessible to residents in care. LPA observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA observed staff preparing lunch for residents during visit. Monitor was observed to be mounted near sink area and accessible to residents, staff, and visitors. LPA Ramirez has addressed this issue on previous visit. .

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. LPA Lopez observed five (5) out of the six (6) residents seated in this area during the visit. (See 809-C for continuation).

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHALET TERRACE SENIOR LIVING
FACILITY NUMBER: 198603532
VISIT DATE: 04/01/2025
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(continue on 809)

Laundry room: LPA observed detergents and disinfectants to be inaccessible to residents in care. LPA Lopez observed two (2) emergency food buckets in laundry cabinet.

Linen Closet: Contained plenty linens, towels, hygiene products and PPE supply.

Resident Rooms 1-3: All resident rooms are shared, and LPA observed a camera mounted in the corner of resident room #3. LPA Ramirez has previously addressed this issue. LPA observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-2: Water temperature in two (2) resident bathrooms were within 105.0 – 120.0 degrees F. Bathrooms were observed to be clean and well stocked. LPA observed signage promoting proper hand washing etiquette.

Backyard: Well, maintained and no hazards were observed. Plenty of shade and seating was observed.

Emergency Drills/Emergency Disaster Plan: Last documented drills were conducted on 03/01/2025. Emergency disaster plan (LIC610) was observed, reviewed and needs updating

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. LPA observed fire extinguisher near kitchen to be fully charged.

Personnel Records: Personnel records are maintained at facility. LPA reviewed staff files for three (3) staff. LPA observed Administrator’s certificate for Amanda Palomino with an expiration date of 06/15/2026..

Resident Records: Five (5) resident records were reviewed. Medication for four (4) residents were reviewed and medication was administered according to doctor’s orders.

Liability Insurance & Infection Control Plan: LPA requested and obtained a copy of liability insurance and infection control plan.

Exit interview was conducted. No deficiencies were observed. Technical Advisories provided. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
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