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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006142
Report Date: 08/20/2025
Date Signed: 08/20/2025 03:33:53 PM

Document Has Been Signed on 08/20/2025 03:33 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MONROY HOME CARE ASSISTANCEFACILITY NUMBER:
306006142
ADMINISTRATOR/
DIRECTOR:		DURAN, WENDY K.FACILITY TYPE:
740
ADDRESS:24322 FORDVIEW STREETTELEPHONE:
(714) 353-6133
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 1DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:13 PM
MET WITH:Licensee - Olga Lugo Garcia
Staff - Wendy Duran		TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit for the required annual inspection. LPA Rodriguez explained the purpose of today’s visit, and was greeted and granted entry by licensee (LE) Olga Lugo Garcia. For this visit, LPA Rodriguez met with staff on duty (S1) Wendy Duran.

For today’s visit, LPA Rodriguez observed a total of 1 resident in care and 2 staff members on duty.

LPA Rodriguez observed the Administrator's Certificate for Wendy Duran which expired on 1/9/2024. LPA Rodriguez observed the PUB 475 "See Something Say Something" poster located in the hallway.

LPA Rodriguez toured the interior and exterior portions of the facility with S1 Duran. The facility is a two level structure and is licensed for 6 non-ambulatory residents, of which 0 may be bedridden, and 3 may be on hospice. On the first floor, there are a total of 3 bedrooms, of which all 3 are shared resident rooms. LPA Rodriguez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. On the second floor, LPA Rodriguez observed that there are 2 bedrooms and 1 bathroom designated only for staff use. LPA Rodriguez observed that there are no resident or resident belongings on the second level, and obtained confirmation from S1 Duran that no residents reside on the second floor.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. On the first floor, there are a total of 3 restrooms. On the second floor, LPA Rodriguez observed 1 bathroom, of which is only designated for staff use. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested and observed to be between 110.9 to 112.1 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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Document Has Been Signed on 08/20/2025 03:33 PM - It Cannot Be Edited


Created By: Celine Rodriguez On 08/20/2025 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MONROY HOME CARE ASSISTANCE
FACILITY NUMBER: 306006142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the administrator certificate for staff 1 (S1) expired on 1/19/2024. It was confirmed by observation, record review and interview, that S1 is not listed on the active or pending list of certified administrators via CDSS website. Further confirmation was obtained from the CDSS Administrator Certification Bureau that there is no record of S1's renewal. Therefore, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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As a plan of correction (POC), S1 will provide up to date documentation that administrator certification renewal is in process. S1 will provide POC to assigned LPA on or by 9/3/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Celine Rodriguez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MONROY HOME CARE ASSISTANCE
FACILITY NUMBER: 306006142
VISIT DATE: 08/20/2025
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care.

Fire extinguisher was mounted, charged, tagged for the date 2023.

LPA Rodriguez observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply located in the garage. LPA Rodriguez observed that First Aid Kit had all the required components. LPA Rodriguez observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Rodriguez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were observed to be self-closing and self-latching. No bodies of water were observed.

LPA Rodriguez reviewed the current resident file and observed that the staff currently present at the facility were background cleared and associated via Guardian.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with S1 Duran.

A copy of this report and appeal rights were provided and explained.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Celine Rodriguez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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