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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603920
Report Date: 03/02/2026
Date Signed: 03/02/2026 02:33:02 PM

Document Has Been Signed on 03/02/2026 02:33 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:HOUSE OF GRACE 5 INC.FACILITY NUMBER:
198603920
ADMINISTRATOR/
DIRECTOR:		SINCLAIR, REBECCAFACILITY TYPE:
740
ADDRESS:202 E CAMDEN STREETTELEPHONE:
(626) 716-1033
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 0DATE:
03/02/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Rebecca Sinclair, Michelle AguirreTIME VISIT/
INSPECTION COMPLETED:
02:40 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 Applicants Rebecca Sinclair and Michelle Aguirre.

The facility has an approved fire clearance to be licensed to serve six (6) non-ambulatory residents age range 60 and over. Hospice waiver approved for six (6).

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

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

Appliances such as a microwave and stove were observed to be clean and operating at the time of visit. Freezer of adequate size maintained a temperature of 0°F, and refrigerator of adequate size with a temperature of 40° F were observed to be clean and operating. Kitchen area was observed to be clean and free of litter, rodents, vermin and insects. Sharps are secured in a locked hall closet, 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: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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: HOUSE OF GRACE 5 INC.
FACILITY NUMBER: 198603920
VISIT DATE: 03/02/2026
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A comfortable, appropriately furnished living room was observed with games, and activities. Dining area was clean with sufficient seating. Fireplace in the dining area has a covering, making it inaccessible. Resident bedrooms have all require furniture which includes, for each resident, a chair, night stand, and lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings. Extra bedding and hygiene supplies were observed in a hall closet. Water temperature was tested and measured 109.7°F and 109.5°F, which is within the required at 105°-120°F. Grab bars and slip-resistant mats were observed in bathrooms.

Combination smoke/carbon monoxide detectors located throughout the facility are interconnected, were tested and are operable. Three (3) fire extinguishers observed and charged. Laundry area was observed in the garage. Washing machine and dryer were observed to be in good repair. The garage included a locked cabinet for detergents and cleaning supplies. Also in the garage were two (2) rooms that will be used as an office and storage.

Centrally stored medication will be located in a locked hallway closet, inaccessible to residents in care. The first-aid kit was observed and is kept in the locked hall closet. Staff and resident files will be secured in a locked hallway closet.

Outdoor activity area is easily accessible to residents, protected from traffic, and has adequate shady area and sufficient seating. Doors, exits, hallways, and passageways were clear and free of obstruction. There are no pools or large bodies of water. There is a small home on the property, located in the backyard. The home has a separate address from the facility, has a separate entrance from the facility and will not be used as Airbnb. The current occupant is the applicant’s family member. The family member is fingerprinted and has a health screening with TB clearance.

The Pre-licensing is completed. Comp III was waived as the Applicant is a licensee and has other facilities.

Exit interview was conducted with applicant Michelle Aguirre 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: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
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