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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603542
Report Date: 02/19/2026
Date Signed: 02/19/2026 05:51:47 PM

Document Has Been Signed on 02/19/2026 05:51 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:GARDENIA GARDEN, INCFACILITY NUMBER:
198603542
ADMINISTRATOR/
DIRECTOR:		MELIKYAN, SONAFACILITY TYPE:
740
ADDRESS:1708 ROYAL OAKS DR.TELEPHONE:
(626) 772-3050
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 6DATE:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:38 AM
MET WITH:Leonisa Agnasin, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. LPA were met by Leonisa Agnasin, Caregiver and LPA explained the p Marebeth Mallare, Administrator and Leonardo Mallare, Caregiver and explained the purpose of the visit. The facility cares for residents age range 60 and over and licensed for (5) non ambulatory, (1) bedridden resident (shall be in bedroom #3), and approved for (6) hospice residents only. There are currently (3) residents on hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.

Operational Requirements: The Infection Control Plan has been reviewed and updated. A Hospice Waiver for six (6) is approved. Valid liability insurance policy is in place. The facility does not handle cash resources for the residents. Latest fire/earthquake drill was conducted on 02/05/2026.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential community. The home consists of living room, dining area, kitchen, four (4) resident bedrooms, one of the bedrooms has a fireplace that is adequately screened, four (4) bathrooms, back yard with swimming pool that is fenced and inaccessible to residents, and laundry area in the attached garage. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Hallway closet had extra linens and towels. Bathrooms have the required grabs bars and non-skid materials. The laundry room is clean and has cleaning supplies inaccessible to residents. Hot water temperature were measured between 109.5 degrees F to 110.8 degrees F which are within the required 105 - 120 degrees F.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542
VISIT DATE: 02/19/2026
NARRATIVE
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Physical Plant/Environment Safety [Cont.]: Carbon Monoxide detectors were tested and operable. All the appliances are clean and are working properly. The common areas such as activity room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. Exit doors have auditory devices that were operating at the time of the visit. There are cameras in the front door, backyard, living room, dining area and kitchen. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. Sharps are locked, secure, and inaccessible to residents. The facility has (3) fully charged fire extinguishers, last serviced on 01/15/2025.

Staffing: A total of three (3) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and are associated to the facility.

Personnel Records-Training: LPA reviewed three (3) staff files which include Personnel Record, Criminal Background Clearance, First Aid/CPR, Health Screening, TB Clearance, Employee Rights, and Staff Training. LPA reviewed that the Administrator did not provide a current Administrator Certificate in file and LPA checked pending Administrator Certificate Renewal Status CDSS (California Department of Social Services) website which did not show the Administrator’s name on the list. LPA reviewed Staff #1 (S1’s) file did not have a Valid First Aid Training.

Resident Rights-Information: Resident personal rights are posted. Visiting policy is posted at a location that is visible and accessible to residents and families. LPA observed that the RCFE (Residential Care for the Elderly) “Let Us No” Complaint (PUB 475) Poster was not posted at the facility.

Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility has an activity calendar, activity supplies, and provides sufficient space to accommodate both indoor and outdoor activities.

Food Service: The kitchen was inspected and has sufficient supply of 2 (two) day perishable & 7 (seven) 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 and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542
VISIT DATE: 02/19/2026
NARRATIVE
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Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses conduct visits on a regular basis. LPA reviewed five (5) residents' medications. Based on record review, LPA observed Resident #1 (R1’s) Medication Administration Record (MAR) for the month of February 2026 was not up to date as initials for three (3) medications were missing initials and was last initialed on 02/02/2026. LPA also observed for Resident #2 (R2’s) MAR for the month of February 2026 was not up to date and not accurate since one medication was initialed from 02/01/2026 to 02/31/2026. LPA observed that Resident #3 (R3) did not have a current MAR in file.

Resident Records-Incident Reports: LPA reviewed five (5) resident files which included face sheet, admission agreements, Physician's Report, Ambulatory Status, TB Clearance, Medical/Functional assessments, Needs and Services Plans, and Personal rights. Based on record review, Resident #6 (R6’s) file did not have documentation of determination for ambulatory status.

Disaster Preparedness: The facility has a complete Emergency Disaster Plan in place and at least two (2) relocation sites. Last Fire and Earthquake Drill was conducted on 02/05/2026.



Residents with Special Health Needs: Three (3) Residents are hospice and palliative care. Based on record review, LPA observed that Resident #1 (R1), Resident #2 (R2), and Resident#4 (R4) to Resident #6 (R6) had half bed rails and R1, R2, and R4 to R6’s file did not have physician's order for bed rails. Based on observation and record review, LPA observed that Resident #3 (R3) had full bed rails and R3’s file did not have a hospice care plan specifying a need for a full bed rail.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Marebeth Mallare.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/19/2026 05:51 PM - It Cannot Be Edited


Created By: Daniel Konishi On 02/19/2026 at 05:11 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: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, LPA observed that the RCFE (Residential Care for the Elderly) “Let Us No” Complaint (PUB 475) poster was not posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Adminstrator will post the RCFE (Residential Care for the Elderly) “Let Us No” Complaint (PUB 475) poster that shall be 20” x 26” in size and be posted in the main entryway of the facility and submit a photo to the LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2026 05:51 PM - It Cannot Be Edited


Created By: Daniel Konishi On 02/19/2026 at 05:11 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: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed Staff #1 (S1’s) file did not have a Valid First Aid Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator will send the Staff #1 (S1's) valid first aid training to the LPA by the POC due date.
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Resident #6 (R6’s) file did not have documentation of determination for ambulatory status which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator will send Resident #6 (R6's) documentation of determination for ambulatory status to the LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/19/2026 05:51 PM - It Cannot Be Edited


Created By: Daniel Konishi On 02/19/2026 at 05:11 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: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that Resident #1 (R1), Resident #2 (R2), and Resident#4 (R4) to Resident #6 (R6) had half bed rails and R1, R2, and R4 to R6's file did not have physician's order for bed rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator will send Resident #1 (R1), Resident #2 (R2), and Resident#4 (R4) to Resident #6 (R6's) physician's order for half bed rails to the LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based one record review and observation, LPA observed that Resident #3 (R3) had a full bed rail and R3's file did not have a hospice care plan specifying a need for a full bed rail which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator will send Resident #3 (R3's) hospice care plan specifying a need for full bed rails to the LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2026 05:51 PM - It Cannot Be Edited


Created By: Daniel Konishi On 02/19/2026 at 05:11 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: GARDENIA GARDEN, INC
FACILITY NUMBER: 198603542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(g)
(g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and staff interview, LPA observed that the Administrator’s file does not have a valid RCFE Administrator’s Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator will send valid RCFE Administrator Certificate to the LPA by the POC due date.
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a centrally administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed Resident #1 (R1’s) Medication Administration Record (MAR) for the month of February 2026 was not up to date as initials for three (3) medications were missing initials and was last initialed on 02/02/2026. LPA also observed for Resident #2 (R2’s) MAR for the month of February 2026 was not up to date and not accurate since one medication was initialed from 02/01/2026 to 02/31/2026. LPA observed that Resident #3 (R3) did not have a current MAR in file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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3
4
Administrator will submit a written statement indicating that they will ensure that the residents' MARs are accurate and up to date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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