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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603572
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:18:06 PM

Document Has Been Signed on 09/30/2025 04:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALAZZO OF DOWNEY, INC., THEFACILITY NUMBER:
198603572
ADMINISTRATOR/
DIRECTOR:		CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:9276 DOWNEY AVETELEPHONE:
(562) 659-7586
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 6CENSUS: 6DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Rowena Carrillo AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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 Licensing Program Analyst’s (LPA’S) Christian Gutierrez, and Gabby Castro conducted an unannounced Annual required inspection to Palazzo of Downey, Inc., The. Upon arrival LPA’s were greeted by the administrator Rowena Marantal and explained the reason for the visit. This home is licensed to serve age range of 60 and over. Fire clearance approved for six (6) ambulatories. Licensed is subject to terms and conditions for hospice waiver approved for four (4) residents. No dementia residents.

The facility is a two-story home located in Downey, Ca. A tour of the facility includes 1st floor: 2 resident bedrooms, 1 full bath, 1 1/2 bath, kitchen dining area, family room, living room, pantry, laundry room, closets, attached garage, front yard and backyard. 2nd (frontal) floor: 5 bedrooms (4 are resident rooms, two (2) with private bath, 1 Administrator office with bathroom), 1 additional restroom, and living room.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. Extra linen was observed in downstairs laundry room. LPA’s observed R4 with full bed rails with no physician’s order. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has two (2) fully charged fire extinguishers which are kept in kitchen and upstairs. Cleaning supplies and toxic substances were observed to be inaccessible in a locked cabinet in kitchen and in laundry room. Knives were locked in kitchen drawers. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility was observed to have sufficient supply of 2 days perishable & 7 days non-perishable foods. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in backyard. Passageways and exits are free of obstruction.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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 7
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 09/30/2025 04:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/30/2025 at 03:03 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 R3 had a physicians report that stated that he/she has dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator will obtain a new physicians report or contact family to make arrangments to locate resident to another facility that can care for dementia.
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 R3 has a physician report that stated that he/she is non-ambulatory which is not approved on fire clearanxe.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator will obtain a new physician report or contact family to make arrangments to locate resident to another facility that can care for non- ambulatory residents.
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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/30/2025 04:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/30/2025 at 03:03 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 S1 did not have a current CPR/First aid cert and is alone with residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator will obtain a new CPR.First aid and send to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation), the licensee did not comply with the section cited above LPA observed medication cabinet to have keys on cabinet door making medications accessible to residnets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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 Administrator l removed keys from cabinet lock*
Licensee/Administrator to review regulation 87465 in its entirety with staff and send a log 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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 09/30/2025 04:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/30/2025 at 03:03 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 six (6) residents were missing medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator will obtain medications and send to LPA. R3 Donepezil 5MG 1 tab daily, R6 lisinopril 40hg 1 tab daily, and R4 Glucophage 1000 mg twice, glucagon injection kit, and vitamins.
Type A
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 on observation, the licensee did not comply with the section cited above R4 did not have order for full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Administrator will remove bed with full bed rails and send picture 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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/30/2025 04:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/30/2025 at 03:03 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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above one (1) out of six (6) bathrooms did not have hot water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Administrator is working to get hot water for upstairs restroom and will send LPA invoices once repaired by POC due date.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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 R2 602 had no dates, R4 602 no signatures or dates, R5 602 expired, and R6 602 expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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Administrator will obtain 602's 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: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
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: PALAZZO OF DOWNEY, INC., THE
FACILITY NUMBER: 198603572
VISIT DATE: 09/30/2025
NARRATIVE
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Two (2) out of four (4) staff files reviewed included criminal clearance record, and health screening with TB. Staff (S1) has expired CPR/First aid and is alone with residents at night, S2 is missing health screening with TB. Six (6) resident files were reviewed, all six (6) were missing appraisal needs and service plan (625), R2 has physicians report 602 with no dates, R4’s 602 has no dates and physicians signature missing, R5’s 602 is expired, and R6’s 602 is expired. During document review it was revealed that R4’s physician report stated that he/she is non-ambulatory and has dementia both not approved in fire clearance. Civil penalties cited. Fire/earthquake drill was conducted in July of 2025. The medications are centrally stored and LPA’s observed key hanging from knobs that are accessible to residents in kitchen cabinet. LPA reviewed medications for six (6) residents and three (3) out of six (6) are missing medication. Mar log is being used.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be detailed on the LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Rowena Marantal Carrillo.

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

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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