<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603822
Report Date: 08/15/2025
Date Signed: 08/15/2025 12:03:01 PM

Document Has Been Signed on 08/15/2025 12:03 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:ANNIKA'S HOME CAREFACILITY NUMBER:
198603822
ADMINISTRATOR/
DIRECTOR:		MARALIT, TERESITAFACILITY TYPE:
740
ADDRESS:1312 E MOUNTAIN VIEW AVETELEPHONE:
(626) 454-0677
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 0DATE:
08/15/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Teresita MaralitTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Blanca Gonzalez conducted an announced Pre-Licensing Inspection visit and met with Applicant Teresita Maralit.

The facility has an approved fire clearance to be licensed to serve a capacity of six (6); five (5) non-ambulatory, one (1) bedridden residents ages 60 and over.

LPA and Applicant toured the physical plant interior and exterior. The Pre-Licensing Inspection CARE Tool was used.

The following was observed/inspected:

The facility is a single-story home located in a residential area of Glendora consisting of: kitchen, dining area, living room, staff room, five (5) resident bedrooms, three (3) bathrooms, front yard, backyard with a pool and an attached garage.

The kitchen contained locked cabinets for securing centrally stored medication and facility/resident files. First aid kit and current manual were observed stored in the kitchen. The refrigerator was clean and stocked with adequate food supply of 2-day perishables, and 7-day non-perishables in the pantry. Sharps were observed secured and inaccessible. Cleaning supplies observed secured under the kitchen sink. LPA observed bugs under the kitchen sink. Applicant indicated they would get Terminix out to treat the facility. LPA requested proof, in the form of receipts, of the pest control service once completed.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2025
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 4
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)
Page: 2 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: ANNIKA'S HOME CARE
FACILITY NUMBER: 198603822
VISIT DATE: 08/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
page 2

Dining area is located in the kitchen.

Living room has a fireplace with a covered screen. Staff room is accessible through the living room.

Hallway linen closet contained surplus clean linens.

Residents bedroom were observed to have the required furniture and sufficient lighting and storage. Resident beds were observed to have clean linens. LPA observed windowsills to be dirty with dead bugs. Applicant stated they would have it cleaned.

Water temperature was checked in three (3) bathrooms and measured below 105 degrees F. Applicant stated they would address the low water temperature by end of day. LPA requested proof, in the form of a video of thermometer showing running water measuring with the range of 105-120 degree F, submitted once corrected.

Walkways on both sides of the exterior of the home contained debris. Applicant stated the debris would be cleared by end of day. LPA requested proof, in the form of photos, to be sent once debris has been cleared.

LPA observed the backyard to have a covered seating area and a pool which was made inaccessible through fencing.

Carbon and smoke combination detectors were observed throughout the facility, were tested and are operable. The facility has two (2) fire extinguishers, and both are observed to be charged.

Comp III was not conducted due to Applicant being a licensee and having other facilities. Facility did not meet the physical plant/inspection requirements as required per California Code of Regulations Title 22.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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: ANNIKA'S HOME CARE
FACILITY NUMBER: 198603822
VISIT DATE: 08/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
page 3

The following Corrections need to be made prior to clearing the facility for License:

· All faucets must have cold and hot water within department regulations of 105-120 degrees F

· All trash bins must have lids

· Sides of the home needs to be cleared of debris

· Home shall be free of pests, bugs

Exit interview conducted and a copy of this report was provided to Applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4