198603908-12-16-2025-28-AS-CDCN-DPF4GD-20251216180521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603908
Report Date: 12/16/2025
Date Signed: 12/16/2025 06:09:34 PM

Document Has Been Signed on 12/16/2025 06:09 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:	ALL FOR MOMS HOMECARE 2		FACILITY NUMBER:	198603908
ADMINISTRATOR/ DIRECTOR:	TRUONG, PHUOC THIEN		FACILITY TYPE:	740
ADDRESS:	16249 DUBESOR ST		TELEPHONE:	(626) 456-1066
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 6		CENSUS: 0	DATE:	12/16/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Phuoc Truong-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:50 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 Analysts ( LPAs) Cynthia Chan and Elena Mallett conducted an announced pre-licensing visit on 12/16/25 with Applicant Phuoc Troung. The fire clearance is approved for 6 residents, ages 60 and over. (1) may be bedridden and (5) can be non-ambulatory. Bedroom # 1 is approved for (1) bedridden resident. The applicant has submitted a request for a hospice waiver to the Centralized Applications Bureau (CAB). The Prelicensing visit was conducted utilizing the CARE (Compliance and Regulatory Enforcement) tool. The following domains were assessed: Infection Control: The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Structure/Physical Plant: The facility is a single-story home in the residential area of La Puente. The home consists of 5 bedrooms. Bedroom room #1 is a shared bedroom with space for one non-ambulatory resident and one bedridden resident. Bedrooms #2- #5 are private rooms for non-ambulatory residents. There is an open living room, dining room area, 2 bathrooms, laundry room, and a kitchen. Bathrooms have non-skid mats in the shower area and grab bars. The backyard has a shaded area with a table and chairs. There is a portable storage shed in the back yard. Residents’ rooms have adequate lighting and the required bedroom furniture. Extra linens and hygiene supplies were observed. Hallways leading to shared bathrooms had night lights. All walkways were free of debris and obstruction. No swimming pool or bodies of water on the premises. The toilets were functioning properly and the hot water temperature measured within required range.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

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: ALL FOR MOMS HOMECARE 2	FACILITY NUMBER: 198603908
	VISIT DATE: 12/16/2025

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Facility has an operable smoke detector in each room and a carbon monoxide detector located near resident rooms. There were 2 fully charged fire extinguishers observed. Knives, cleaning solutions, and disinfectants are locked. No firearms or weapons stored at the facility. The facility has an auditory device on each exit door. Video surveillance was observed in the common areas.
Food Service:
There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. The kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The refrigerator is maintained at 40 degrees F or below and the freezer at 0 degrees F or below. The knives and sharps are stored and locked in a cabinet.
Staff and Residents files:
Staff and Residents files will be stored in a locked cabinet near the dining room.
Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. A list of planned activities was provided.
Incidental Medical and Dental: Medications will be centrally stored and locked inside a cabinet near the dining room. The first aid kit was observed to contain all the required supplies along with the current first aid manual.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility will accept and retain residents with dementia and/or hospice.

The facility phone number is (323) 258-8879.

Component III was conducted with the applicant. The physical plant is cleared; however, the following shall be submitted to LPA and the CAB Analyst by 12/23/25.
· verification of the Complaint poster with 20” X 26” in size
· Long Term Care Ombudsman poster
· Update Plan of Operation to include video surveillance (refer to EM 2-5800) and submit to CAB for review
· Liability insurance shall be secured upon licensure.

An exit interview was held, and a copy of this report was given to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC809 (FAS) - (06/04)

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