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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603661
Report Date: 01/22/2026
Date Signed: 01/22/2026 03:13:15 PM

Document Has Been Signed on 01/22/2026 03:13 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:EXCELLENCE BOARD AND CARE LLCFACILITY NUMBER:
198603661
ADMINISTRATOR/
DIRECTOR:		ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:12551 DOWNEY AVE.TELEPHONE:
(818) 799-7218
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 3DATE:
01/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Ivy Jane BertulfoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Licensee Rey John Bertulfo and Administrator Ivy Jane Bertulfo and explained reason for visit. The facility is licensed for an age range 60 and over. Fire clearance approved for six (6) non-ambulatories where four (4) can be bedridden in room #5,6,7 and 8. Room #3 and #4 is for non-ambulatory only. Waiver/granted for hospice care for six (6) residents. Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. LPA observed cameras in each resident’s bedroom that can be viewed on an app called LA view from staff I pad. Extra linen was observed in hallway storage cabinets. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has multiple fully charged fire extinguishers located throughout the facility. Cleaning supplies and toxic substances were observed to be inaccessible in a locked cabinet in laundry area, knives were locked in kitchen cabinet. 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 7 days non-perishable foods and enough 2-day perishable foods for three (3) residents. During tour of facility LPA observed an open can of Budweiser beer in bathroom #4, a case of unopened beer in laundry room, and a trash can in garage filled with empty beer cans. Staff stated they had a late holiday party and residents were asked not to go outside during the party. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. Bathroom #3 sink was not working. LPA observed a file cabinet with key in lock with residents’ medication accessible to residents in care. 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. LPA observed chairs, metal and other debris in back yard.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2026
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 01/22/2026 03:13 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/22/2026 at 02:18 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: EXCELLENCE BOARD AND CARE LLC
FACILITY NUMBER: 198603661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 medication key was left in file cabinet making medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Licensee will conduct training with staff on section 87465(h)(2) and return to LPA by POC due date.
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:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/22/2026 03:13 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/22/2026 at 02:18 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: EXCELLENCE BOARD AND CARE LLC
FACILITY NUMBER: 198603661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 backyard had old furniture, metal, and other debris in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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Licensee will clear backyard and send LPA pictures by POC due date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 bathroom #3 sink did not work at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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Licensee will call plumber and have sink fixed and send receipts 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: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 03:13 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/22/2026 at 02:54 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: EXCELLENCE BOARD AND CARE LLC
FACILITY NUMBER: 198603661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:87468.1 Personal Rights of Residents in All Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above all three residents had cameras in bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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Licensee removed cameras at time of visit. Licensee can submit a facility wide waiver for cameras in private areas, or submit individual exceptions for each resident.
Type B
Section Cited
CCR
86468.2(a)(1)


This requirement is not met as evidenced by:87468.2 Additional Personal Rights of Residents in Privately Operated Facilities

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.


Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed open alcohol accessible to residents at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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Licensee will have a meeting with staff to discuss no alcohal allowed at facility. Licensee will also do insepections of staff rooms to insure they are following rules. Licensee will draw up paperwork with staff and have staff sign 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: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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