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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603885
Report Date: 09/04/2025
Date Signed: 09/04/2025 12:26:39 PM

Document Has Been Signed on 09/04/2025 12:26 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:DIGNITY FIRST ASSISTED LIVING FACILITYFACILITY NUMBER:
198603885
ADMINISTRATOR/
DIRECTOR:		HALLADJIAN,PAULINEFACILITY TYPE:
740
ADDRESS:1016 EAST LEADORA AVETELEPHONE:
(626) 376-6144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 0DATE:
09/04/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Pauline Halladjian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an announced Pre-Licensing inspection visit. LPA met with Administrator Pauline Halladjian and Kevork Halladjian explained the reason for the visit.

The facility has an approved fire clearance to be licensed to serve six (6) residents; five (5) non-ambulatory and one (1) bedridden. Bedroom #3 with direct exiting to the exterior shall house the one (1) bedridden resident. All other rooms will be non-ambulatory.
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 two-story home located in a residential neighborhood of Glendora. The home consists of 3 bedrooms, 2 bathrooms, and hal-bath for staff located near dining area, kitchen, two (2) living rooms, dining area, laundry area, backyard with a pool and an attached garage.
The second floor is inaccessible to residents and will be utilized as an office and staff area.
Smoke and carbon monoxide combination detectors observed, tested and are operable. The fire extinguisher located in the dining are was observed and charged.
Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps were observed secured under the kitchen sink, inaccessible to residents.
continued on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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)
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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: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885
VISIT DATE: 09/04/2025
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continued from LIC809, page 2

Centrally stored medication will be located in a locked cabinet located in the kitchen.
Staff and client files will be maintained locked in a cabinet located in a hallway closet.
Dining area was observed clean with sufficient seating for six (6) residents. Fireplace in dining area is not operational. Living rooms were observed free of obstructions with sufficient seating and space to promote and facilitate the program of activities. Fireplace in the living room had a covered screen.

All cleaning solutions and disinfectants were observed locked under the kitchen sink, laundry area and garage.

Grab bars and non-skid mats were observed in the hallway bathroom. The shower in the private bathroom located in a resident bedroom will not be utilized. The water temperature was tested in both bathrooms and measured at 116 and 112.6 degrees F, within the required 105-120 degrees F.

Residents’ bedrooms have all required furniture which include, for each resident, a bed equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding, fillings and covers for mattresses and pillows were flame retardant, a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers. Bed linens were clean and in good repair. There was closet space for clothing and other belongings. Extra clean linens were observed in the hallway storage cabinet.
No bedroom of a resident shall be used as a passageway to bathroom or outdoors.
Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris.

LPA observed the backyard to have a covered seating area with sufficient seating for six (6) residents and a pool which was made inaccessible through fencing. LPA observed a locked pool gate that opens away from pool and self-latches. LPA observed the surrounding area did not have any objects that can be used to climb over the fence.

continued on LIC 809

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

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885
VISIT DATE: 09/04/2025
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Backyard contained a pool house for private use, locked and inaccessible to residents. Per facility sketch (additional area 2) contains separate, private living quarters, possibly for staff.

LPA provided applicant with the following information:

• PIN 24-03-ASC, Subject: Safety Requirements for Facilities with Pools and Other Bodies of Water
• LIC 311F, Records to be Maintained at the Facility- Residential Care Facility for the Elderly

Comp III was completed during today’s visit with applicant Pauline Halladjian.
The Pre-licensing is complete, and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been 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: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4