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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603962
Report Date: 02/20/2026
Date Signed: 02/20/2026 12:35:08 PM

Document Has Been Signed on 02/20/2026 12:35 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:CHARVERS RESIDENCEFACILITY NUMBER:
198603962
ADMINISTRATOR/
DIRECTOR:		LOPEZ, LORRAINEFACILITY TYPE:
740
ADDRESS:536 S CHARVERS AVETELEPHONE:
(626) 890-7634
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 0DATE:
02/20/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Lorraine Lopez - Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an announced Pre-Licensing facility Evaluation visit. LPA met with Lorraine Lopez, Applicant/Administrator and Claudia Murillo, House Manager who assisted LPA with the visit. The facility is in a residential neighborhood in the city of West Covina. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following are observed:

Physical Plant & Environment Safety: The facility is a single story house and located in a residential area.This single-story home contains six (6) bedrooms, three (3) bathrooms, a living room, family/TV room, kitchen, dining room, breakfast nook, backyard with swimming pool and gazebo, and attached garage. The hot water temperature in (2) bathrooms were tested and did not meet the required 105-120 deg F. Bathroom #1 was measured at 92.4 deg F and bathroom #2 measured at 84.6 deg F after checking it 3x. Bedrooms are large enough to allow for easy passage and comfortable for usage of beds and other required items of furniture. LPA observed low beds in bedrooms #1, 4 and 6. Cleaning solutions, laundry soap and disinfectants are stored in a locked portable cart. Sufficient supply of linens available to permit weekly changing are available. Sufficient personal hygiene supply available. The signal systems in all exit points are operating properly. The laundry machines are operable and located inside the home. Smoke detectors/carbon monoxide detectors were tested and operable. Fire extinguishers are observed in the home and garage which were serviced on 12/04/2025. Knives and sharps were locked and stored in a metal box. Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary. The home has a video camera monitor system in the common areas, no audio. Doors, exits, hallways, and passageways were clear and free of obstruction. LPA observed a spa/pool in the backyard that is gated.


Operational Requirements: The Infection Control Plan has been submitted to CCL and the CAB Analyst. Fire clearance granted. Bedroom #6 is approved for bedridden, all other bedrooms are approved for non ambulatory. No delayed egress was approved at this time. Applicant stated that she will not handle resident's cash resources. Telephone is easily accessible and available for residents' use.
***CONTINUED ON LIC 809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2026
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: CHARVERS RESIDENCE
FACILITY NUMBER: 198603962
VISIT DATE: 02/20/2026
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Staffing: The administrator has a valid administrator certificate, expiring on 11/13/2027.
Personnel Record/Staff Training: All staff files will be maintained in the facility and will be locked in a cabinet.
Resident Records/Incident Reports: All residents files will be maintained in the facility and will be locked in the kitchen cabinet.
Resident Rights-Information: The home has adequate furnishings and equipment to meet the residents' needs. LPA observed the Theft and Loss policy, Visitation policy, Personal rights, Non-discrimination notice, Long Term Care Ombudsman and labor information posted in the home.
Food Service: Meals will be stored and prepared in a safe manner, necessary to meet the needs of residents. Toxic substances are stored in a locked portable cart. Food storage and preparation areas, which include pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit.
Residents with Special Health Needs: The facility is approved for (1) bedridden resident. The facility has operating signal system in exit points.
Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Incidental Medical and Dental: The facility has a complete first aid kit with updated first aid manual. All the residents medications will be stored and locked in the kitchen cabinet. Facility has a safe container to dispose syringes and needles. List of emergency contacts such as Police, Fire Dept. or paramedic unit was completed and posted near the entrance.
Disaster Preparedness: The home has a complete Emergency and Disaster Preparedness Plan that includes, EVAC Procedures, Transportation arrangements, Location of all utility shut-off valves and instructions for use. There is a contact information list of local emergency response personnel, local emergency contact name posted and visible to staff and residents.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility did not meet the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

The following corrections need to be made prior to clearing the physical plant:

  • Hot water temperature needs to be adjusted and must meet the Title 22 Regulations requirements of hot water reading to be between 105-120 deg F.
  • Secure the fireplace in the family/TV room.

LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the pre-licensing facility evaluation visit report, as well as the items needing corrections.

Exit interview conducted and a copy of this report has been furnished to the applicant/administrator Lorraine Lopez. 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC809 (FAS) - (06/04)
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