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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603550
Report Date: 01/21/2026
Date Signed: 01/21/2026 04:02:30 PM

Document Has Been Signed on 01/21/2026 04:02 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:WEST PARK SENIOR LIVINGFACILITY NUMBER:
198603550
ADMINISTRATOR/
DIRECTOR:		JERI MILESFACILITY TYPE:
740
ADDRESS:801 CYPRESS WAYTELEPHONE:
(909) 592-8844
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 200CENSUS: 111DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Jeri Miles DirectorTIME VISIT/
INSPECTION COMPLETED:
04:17 PM
NARRATIVE
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Licensing Program Analysts (LPA) Christian Gutierrez conducted the required annual inspection. LPA met with Administrator Jeri Miles and discussed the purpose of today’s visit.

This facility is approved for (81) ambulatory and (119) non-ambulatory residents (of which 10 may be bedridden). This facility has an approved hospice waiver for (15) residents. The following bedrooms are approved for bedridden residents: #206,207,208,209,210,106,107,108,109 and 110.

A tour of the facility contains 2 buildings: Building #1 has 2 floors, first floor containing a lobby, 5 offices, ballroom, staff break room, store, salon, 2 community men's restrooms, 2 community women's restrooms, pantry, mail room, kitchen, private dining room, dining room and a living room. Building #2 contains 7 floors. First floor contains a medication room, activity room and 23 resident bedrooms, each with its own bathroom. From the second floor to the seventh floor: Each floor contains 24 resident bedrooms, each with its own bathroom, laundry room, community restroom and an activity room.

SEE LIC 809C

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
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)
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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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Document Has Been Signed on 01/21/2026 04:02 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/21/2026 at 03:01 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: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above the sixth and seventh floor of buliding are being treated as independent living without approval from department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator will submit all required documents for R5 -R6 admission agreements, conset forms, current 602's, personal rights, and appraisel needs and service plans and update all forms for the rest of residents on 6th and 7th floor.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above insurance expired 10/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator will submit current insurance to 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:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2026 04:02 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/21/2026 at 03:01 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: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above three (3) out of eight (8) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator will send completed training for S4, S7, and S8 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:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2026 04:02 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/21/2026 at 03:01 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: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central 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, the licensee did not comply with the section cited above four (4) out of six (6) residents were missing paperwork from file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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R1- Admission agreement and personal rights, R2 -conset form, R4- current 602 with TB, R5- admission agreement,new 602, conset forms, and appraisel needs and service plan, and R6- conset forms, personal rights, and appraisel needs and service plan.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above no drill were avaliable for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator will conduct drills and send to 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:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: WEST PARK SENIOR LIVING
FACILITY NUMBER: 198603550
VISIT DATE: 01/21/2026
NARRATIVE
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Resident bedrooms were randomly chosen for review on each floor. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grab bars and non-skid mats. The hot water was between 109.4-115.3 degrees, which is within the required 105 - 120 degrees. Multiple carbon monoxide detectors were observed on each floor (tested and operable). Fire extinguishers are located throughout the facility and on each floor. Kitchen was inspected. There is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, living room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction.

Eight (8) staff files were reviewed and included Criminal clearance record, and health screening with TB. Three staff did not have the required training, four (4) out of six (6) residents files that were reviewed were missing admission agreements, current physicians report with TB reading, consent forms, and appraisal needs and service plans. No fire/earthquake drill was conducted. Infectious control plan was reviewed. Facility had insurance that expired October of 2025. After record review it was discovered that facility did not follow operation plan for sixth and seventh floor. Random resident medications were reviewed. No errors observed. Medications are centrally stored and locked.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
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)
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