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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603532
Report Date: 02/24/2026
Date Signed: 02/24/2026 01:35:30 PM

Document Has Been Signed on 02/24/2026 01:35 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:
02/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:44 AM
MET WITH:Amanda Palomino,Administrator and Evangelina Reyes, Co-Administrator TIME VISIT/
INSPECTION COMPLETED:
01:39 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual required 1-year visit. . LPA was met by Evangelina Reyes, Co-Administrator and Administrator Amanda Palomino arrived a short time later and also assisted with the visit. LPA explained the purpose of 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). One (1) out of the six (6) residents in care is currently on hospice care.

LPA OBSERVATIONS:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and but does have an Infection Control Plan.

Physical Plant: The facility is a single-story dwelling located 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.

LPA Lopez observed knives and sharps located in kitchen cabinet, to be inaccessible to 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. Water temperature in two (2) resident bathrooms was within 107.1 -107.4 degrees F. which is within range. Bathrooms were observed to be very clean and well stocked. LPA observed signs promoting proper hand-washing etiquette. (See 809-C for continuation).

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2026
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: 02/24/2026
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(continued from 809)
LPA observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens, towels, and hygiene products. LPA observed detergents and disinfectants to be inaccessible to residents in care. LPA Lopez observed two (2) emergency food buckets in laundry cabinet. Dining room was observed to be clean and contained one table with plenty of seating. Yard was observed to be well maintained and no hazards were observed. Plenty of shade and seating were observed.

3. Operational Requirements: The facility maintains a fire clearance approved by the fire department. The facility has shaded area with table and chairs for residents to utilize for outdoor area. The last fire/disaster drill was conducted on 09/01/2025. LPA reviewed and verified facility liability insurance which expires on 03/16/2026

4. Staffing: The facility has sufficient staff, and the night supervision staff did receive planned emergency training.

5. Personnel Record-Training: All the staff files are maintained at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Amanda Palomino certificate expires on 06/15/2026. All the direct care staff received Medication Management Training. All first aid training certificates for staff are current.

6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.

7. Resident Rights-Information: The Complaint, ombudsman and residents personal rights are posted by the main entry. Visiting hours were posted at facility.

8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. LPA observed staff assisting in activities for residents during visit.

(continued on 809C)

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

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC809 (FAS) - (06/04)
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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: 02/24/2026
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(continued from 809C)

9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents.

10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed four (4) residents' medication files, and all medications are administered according to Doctor’s orders.

11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents.

12. Residents with Special Health Needs: No residents have prohibited health conditions.

No deficiencies observed during today’s visit. Exit interview conducted and copy of report and appeal rights were provided.

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

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC809 (FAS) - (06/04)
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