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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603892
Report Date: 09/16/2025
Date Signed: 09/16/2025 12:50:22 PM

Document Has Been Signed on 09/16/2025 12:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PALOMINO RESIDENTIAL CAREFACILITY NUMBER:
198603892
ADMINISTRATOR/
DIRECTOR:		PALOMINO, BORISFACILITY TYPE:
740
ADDRESS:1401 PIEDRA WAYTELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 0DATE:
09/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Amanda and Boris Palomino, Licencee and Administrator TIME VISIT/
INSPECTION COMPLETED:
12:54 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) Alberto Lopez conducted an “announced” PRE-LICENSING visit to the facility and met with Licensee Applicant/Administrator Boris and Amanda Palomino. Licensee Applicant is a corporation [PALOMINO RESIDENTIAL CARE, INC] and Administrator [Boris Palomino] is designated for the facility. Licensee will operate a business as Palomino Residential Care inc. Component III was not required. Facility has an approved fire clearance for six (6) non-ambulatory residents (age 60 and above), including one (1) bedridden in room two (2), and was granted on 08/18/2025.
Physical plant was toured inside and out. Facility is equipped with smoke detectors (inter-connected w/battery backup), fire alarm device, and carbon monoxide system. Bedroom #1 is a shared bedroom with no bathroom. Bedroom #2 is a shared bedroom with no bathroom. Bedroom #3 is a private room for one (1) resident Bedroom #4 is a private room for one resident. The bedrooms are set up with beds, nightstands with sufficient lighting, dressers, and closet space. The supply of extra bedding and bath linens is adequate. All resident rooms are equipped with smoke detectors, and the facility smoke alarm system is synchronized with battery backup. The common bathroom in the living room has a toilet with grab bars.

The common areas (living room and dining area) were appropriately furnished, and the lighting is adequate. There is a fireplace in the living room that the licensee stated gas was capped and will not be used. LPA observed controls removed from fireplace. Fire extinguisher (located in the kitchen area) is fully charged and was inspected on June 11, 2025. Medications will be stored in a locked cabinet (located in the kitchen area). A first-aid kit was complete with first-aid manual and stored in the locked cabinet in the kitchen area.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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 3
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PALOMINO RESIDENTIAL CARE
FACILITY NUMBER: 198603892
VISIT DATE: 09/16/2025
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
(continued from 809)

Kitchen cleaning supplies and other toxins are stored in a locked cabinet under the kitchen sink. The laundry room with washer and dryer has a secure cabinet for laundry detergents and are in a locked cabinet in the laundry area. The hot water temperature measured between 108.6 - 112.6 which is within the required range of 105.0 -120.0 degrees F. The Facility Administrator stated that the facility will have phone service transferred from the current facility next door on same day of approval. The administrator agreed to not install or use any video cameras in private rooms until the department has approved the use of video cameras in the private rooms. During the visit, LPA observed all four (4) resident rooms with no video cameras installed. Two (2) rooms have the hardware for video cameras and Licensee agreed to not install video cameras until approval is granted by the department. Licensee was asked and agreed to send an updated facility sketch to California Application Bureau (CAB) showing the absence of video cameras in the four (4) resident’s room.

There is a locked drawer in the kitchen where the knives will be stored and inaccessible to residents. The supply of perishable and non-perishable food is adequate. The supply of dishes is adequate. Appliances (stove, oven, microwave, refrigerator, dishwasher) in the kitchen are functional.

The front yard is well landscaped with one palm tree. The backyard is secured with a self-closing gate and patio cover. LPA observed the patio furniture with appropriate shade. LPA did not observe bodies of water in the backyard. The trash cans have covered lids. There is an attached garage used for storage and not accessible to residents. The licensee cleared all obstructions from outside of the home during the visit.

Facility has current disaster plan with relocations sites and approved plan of operation.

Facility is ready for license

LPA will submit the Pre-Licensing Report to CAB. Licensee was advised to contact their CAB analyst with further questions. An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator Boris and Amanda Palomino.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3