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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 10/27/2025
Date Signed: 10/27/2025 01:16:45 PM

Document Has Been Signed on 10/27/2025 01:16 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:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR/
DIRECTOR:		ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 3DATE:
10/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Margie Isidro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1, 1 non-ambulatory in room #2, 2 non-ambulatory in room #3, and 1 ambulatory). There is a Hospice waiver for 2 residents.

The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are vacant), 2 full bath (1 full bath is inside room #1), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an ADU in the back yard that Administrator resides in, there are no residents living in ADU.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit observed the following:


Infection Control: Facility maintains the required Infection Control Plan.
Operational Requirements: There's an approved fire clearance and maintain the required liability insurance.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Residents with Special Health Needs: There currently are no residents on hospice at the facility.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 9/18/25. (Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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 6
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 10/27/2025 01:16 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/27/2025 at 12:09 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: HOME 'R US
FACILITY NUMBER: 198603657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during medication review, the licensee did not comply with the section cited above as there there was a pill box dated Sun-Sat that per converstation with Administrator is being used for medications, med box had medication in the Wed/Thurs slots, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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*LPA explained that the pill box can not be used and medication must be stored in original containers, Administrator agreed to discontinue use of the Pill Box*
Licensee/Administrator to review the regulation listed above, upon completion of reviewing and understanding the requlation they are to fill out and sign the LIC9098-POC form provided during todays visit and submit a copy to LPA via email by POC due date. tena.herrera@dss.ca.gov
Type A
Section Cited
CCR
87465(c)(3)
(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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 as Resident 2 and 3 were missing PRN medications that were listed in their medication list, additionally Resident 2 had PRN medications that have been used and are not listed on current physician medication list, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2025
Plan of Correction
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Licensee/Administrator to call both residents physicians and obtain a copy of the most current medication list, and update refill/remove medications as needed to match the current doctors orders. A copy of the updated Medication list and photos of medication are to be emailed to LPA by POC due date. tena.herrera@dss.ca.gov
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:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/27/2025 01:16 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/27/2025 at 12:09 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: HOME 'R US
FACILITY NUMBER: 198603657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

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 as Resident # 2's last complete physician report is dated 8/15/24 and there is no idications stating that resident has refused any visits with physician, therefore, the yearly physician report has not been completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator/Licensee provide LPA with an updated (complete) physician report to LPA for Resident #2 by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 Resident # 1's last dated Appraisal is dated 2/29/24 and has not been done for the 2025 year and Resident #2's Appraisal is not dated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator/Licensee provide LPA with an updated Appraisal for both Resident #1 and Resident #2 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:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: HOME 'R US
FACILITY NUMBER: 198603657
VISIT DATE: 10/27/2025
NARRATIVE
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Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured outside the required range of 105-120 degrees F, restrooms water temperatures ranged from 90.8-100.8 degrees F (citation issued and details will be documented on LIC809-D page). All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Staffing: There are currently 2 staff for facility, Administrator stated since there are only 3 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files with no issues observed. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/2/26. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. Although residents have their initial appraisal and physician reports, Resident # 1's last Appraisal is dated 2/29/24, Resident # 2's last complete physician report is dated 8/15/24.(citation will be issued and documented on the LIC809-D page) Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked cabinet. LPA reviewed 2 residents’ medications and observed the following. LPA observed Resident #2 was missing 2 medications that are listed on the Medication list and there were other medications stored in basket that are not listed on medication list, for Resident #3 there were 4 mediations listed on the doctors medication list that were not at the facility, also LPA noticed facility is using medication pill box Sun-Sat with pills inside the Wed/Thurs slots. (812 with details of medication and residents names provided, citations will be issued and detailed on LIC809-D page).

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

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/27/2025 01:16 PM - It Cannot Be Edited


Created By: Tena Herrera On 10/27/2025 at 12:46 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: HOME 'R US
FACILITY NUMBER: 198603657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(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 as during visit LPA tested the water temperature in all bathrooms and the water was below the range measuring between 90.8-100.8 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee/Administrator to adjust the water temperature and monitor it for the next 3 days, a log must be created and water must be tested 3x daily (morning/day/evening) and documented on the log with the date/time/water temp reading and submit a copy of log with all readings within the required range and email a copy to LPA by POC due date. (log must begin 10/28/25 and end 10/30/25)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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