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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603716
Report Date: 10/23/2025
Date Signed: 10/23/2025 11:44:43 AM

Document Has Been Signed on 10/23/2025 11:44 AM - 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:ST. CECILIA'S SENIOR HOME VFACILITY NUMBER:
198603716
ADMINISTRATOR/
DIRECTOR:		VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:1525 E LEVEL STTELEPHONE:
(909) 802-9144
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
10/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Tiffany VanderPoorten-LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Vaid conducted an announced annual inspection. LPA was allowed entry by Marilyn Figueroa-DSP, informed Tiffany Vander Poorten, administrator/licensee who arrived shortly after and assisted with the inspection. The capacity is six (6). Facility has an approved Dementia Care Plan. Hospice waiver is approved for six (6). Currently five (5) residents are residing.

The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, dining room/living room with TV, laundry room, family room, administrator office, kitchen, and detached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to residents. Fire clearance was granted for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place.
Auditory devices are installed at all exits and operable. Bedroom#1 and #2 are approved for one (1) non- ambulatory in each room. Bedrooms #3 and #4 are approved for two (2) non- ambulatory in each room. Garage is not approved for residents or staff residence. Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage.
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower. Adequate supply of linen, wash clothes and towels are observed. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Continued on 809C.....
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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: ST. CECILIA'S SENIOR HOME V
FACILITY NUMBER: 198603716
VISIT DATE: 10/23/2025
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Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has required items. First Aid manual from American red cross was available for staff use and inaccessible to residents. Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom.
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.
Outdoor activity area is furnished with chairs and table and in compliance.
Locked cabinets for records of staff and residents are installed and available. Residents file are observed
Water Tested at 117.6 degrees Fahrenheit. Menus are available for review. Free landline telephone is available for residents’ use and operable. Fire extinguishers are available in the facility. They are fully charged.


Exit conference was conducted, copy of this report was provided to Licensee Tiffany Vander Poorten.

Technical Violation regarding proper recording of medications was provided and discussed. Licensee will update the Medication administered record, provide proof for five residents Medication Administered Record.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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