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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603890
Report Date: 11/24/2025
Date Signed: 11/24/2025 03:52:24 PM

Document Has Been Signed on 11/24/2025 03:52 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:GOOD NESTS II, THEFACILITY NUMBER:
198603890
ADMINISTRATOR/
DIRECTOR:		MONTOYA, TIFFANYFACILITY TYPE:
740
ADDRESS:759 W DIKE STREETTELEPHONE:
(951) 444-5957
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 0DATE:
11/24/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Tiffany Montoya, ApplicantTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an announced visit to the facility for the purpose of a Pre-licensing inspection. LPA met with Applicant Tiffany Montoya.

The facility has an approved fire clearance to be licensed to serve six (6) non-ambulatory residents age range 60 and over of which one (1) may be bedridden. Bedroom #2 with direct exiting to the exterior shall house the bedridden resident.

The facility is a single-story home located in a residential area of Glendora. The home consists of kitchen, dining area, living room, den, three (3) bedrooms, two (2) bathrooms, backyard and garage with laundry area.

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

Infection Control: Facility has an Infection Control Plan in place.

Physical Plant and Environmental Safety:

Appliances such as a microwave and stove were observed to be clean and operating properly. Freezer of adequate size maintained and refrigerator of adequate size observed to be clean and operating properly. Kitchen area was observed to be clean and free of litter, rodents, vermin and insects. Containers storing waste were observed in good repair, free of leaks.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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: GOOD NESTS II, THE
FACILITY NUMBER: 198603890
VISIT DATE: 11/24/2025
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continued from LIC 809 (page 2)

Sharps secured in a locked kitchen cabinet, inaccessible to residents. Disinfectants, cleaning solutions, and poisonous substances stored in areas separate from food supplies. Telephone service on the premises


A comfortable, appropriately furnished living room and en, available to all residents for their relaxation and for entertaining friends and relatives, was observed with games and magazines. Dining area was clean with sufficient seating. Fireplace in the living room had screened covering.

Combination smoke/carbon monoxide detectors located throughout the facility are interconnected, were tested and are operable. Laundry room observed in the garage included a locked cabinet for detergents. Washing machine and dryer were observed to be in good repair. Two (2) fire extinguishers observed and charged.

Resident bedrooms all have required furniture which includes, for each resident; a bed, a chair, nightstand, and lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings. Extra linens and towels observed in hall closet. Water temperature was tested and measured at 133°F, which is above the required 105°-120°F in both bathrooms. Applicant adjusted at time of visit. Grab bars were observed in showers and by toilets in bathrooms used by residents. Slip-resistant flooring was observed in shower floors.

Residents Rights: Personal Rights are posted in common area.

Centrally stored medication will be located in a locked kitchen cabinet, inaccessible to residents in care. The first-aid kit and manual were observed and kept in the kitchen.

Outdoor activity area that is easily accessible to residents, protected from traffic, and adequate shady area was observed. Doors, exits, hallways, and passageways were clear and free of obstruction. No pools or large bodies of water were observed.

Continued LIC809C

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

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
Page: 4 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: GOOD NESTS II, THE
FACILITY NUMBER: 198603890
VISIT DATE: 11/24/2025
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Disaster Preparedness: Facility has Emergency Disaster Plan LIC 610 in place. Applicant will add an addition temporary location, outside the immediate area where facility is located.

The Pre-licensing inspection is completed. Comp III was waived, applicant completed Comp III at the Riverside RO June 2025.

Exit interview was conducted with applicant Tiffany Montoya and a copy of this report was provided. 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: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4