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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603712
Report Date: 12/02/2025
Date Signed: 12/02/2025 04:31:06 PM

Document Has Been Signed on 12/02/2025 04:31 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:GRANT SERENITY OF MONROVIA INCFACILITY NUMBER:
198603712
ADMINISTRATOR/
DIRECTOR:		GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:823 E LEMON AVETELEPHONE:
(818) 425-6797
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 6CENSUS: 5DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Edwin Leonel, Caregiver and Araceli Sanches Alvarez, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA was allowed entry by Edwin Leonel, Caregiver and Araceli Sanches Alvarez, Caregiver and LPA explained the purpose of today's visit. Administrator Diana Castellanos arrived shortly after and assisted LPA with the inspection.

On today's date, LPA inspected the ten (10) domains include: Infection Control, Operational Requirement, Physical Plant/Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.



Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over, of which (1) may be bedridden. Waiver granted for (2) hospice care. Current census is six (6) of which one (1) is under hospice care. Home consists of six (6)resident bedrooms, 2 bathrooms, living room, dining room, kitchen, backyard, and a detached garage being used as a staff rest area. The interior and exterior physical plant was inspected. LPA inspected residents’ rooms and each resident bedroom has the required furniture such as bed frames, dressers, nightstand, lamps, and chairs. Bedrooms also have sufficient closet space. Extra linens and towels are in each resident's bedroom closet.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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: GRANT SERENITY OF MONROVIA INC
FACILITY NUMBER: 198603712
VISIT DATE: 12/02/2025
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Physical Plant/Environment Safety [Cont.]: Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and Carbon monoxide detectors were tested and are operational. The facility has (2) fire extinguishers in the facility which were last serviced on 09/04/2025. There are cameras in the common areas. Cleaning supplies and toxic substances are locked and inaccessible to clients. The hot water temperature readings measured 116.7 deg F in bathroom #1 and 114.9 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit.

Operational Requirements: A fire clearance is in place. Valid Liability Insurance policy is in place. The Last Fire Drill was conducted on 11/12/2025. The Last Disaster Drill was conducted on 11/12/2025. Care and supervision to meet the residents’ needs was observed. Special equipment and supplies to meet the persons with special needs were observed.

Staffing: A total of nine (9) caregivers including the (2) Administrators 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 Four (4) staff files which include Personnel record, health screening, TB clearance, Employee Rights, and First Aid/CPR training. Administrator’s Certificate Expires on 01/06/2027.

Resident Rights-Information: Resident personal rights are posted. Residents have access to internet and the telephone.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-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. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. 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: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: GRANT SERENITY OF MONROVIA INC
FACILITY NUMBER: 198603712
VISIT DATE: 12/02/2025
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Incident Medical and Dental: Medication are centrally stored in a locked cabinet next to the kitchen area. LPA reviewed five (5) residents’ medications. Medications are given as prescribed. First Aid Kit was inspected and has all required items.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. The Last Fire Drill was conducted on 11/12/2025. The Last Disaster Drill was conducted on 11/12/2025.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.***

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to Administrator, Diana Castellanos.

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

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4