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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221043
Report Date: 05/22/2025
Date Signed: 05/22/2025 04:59:49 PM

Document Has Been Signed on 05/22/2025 04:59 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:HOMES FOR LIFE FOUNDATION WILSON HOUSEFACILITY NUMBER:
191221043
ADMINISTRATOR/
DIRECTOR:		LIESS, CAROLFACILITY TYPE:
735
ADDRESS:54 N. WILSON AVETELEPHONE:
(626) 568-3657
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 8CENSUS: 8DATE:
05/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Esperanza Garcia - CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Esperanza Garcia and explained the reason for the visit.

Facility is licensed to serve 8 ambulatory clients between the ages of 18-59 years old. Facility is a two story house with 4 client bedrooms, 2 clients bathroom, 1 live-in staff bedroom, 1 staff bathroom, living room, dining room, kitchen, an office, detached garage, front and back porch with laundry room area, and a shaded outdoor sitting area.

The following CARE tool domains were reviewed during this visit:

Infection Control: An infection control plan was reviewed. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.



Physical Plant & Environmental Safety: LPA toured the facility with Katrin Silvestro Supportive Services Coordinator and observed the facility is under renovation and construction has been done. Kitchen was observed clean. A knife was observed in a cabinet accessible to the clients. The living room has a covered fireplace. The dining room was observed obstructed by furniture due to the remodeling. LPA observed a total (4) client bedrooms, each was observed with sufficient lighting, bedding supplies, and furniture. LPA observed (2) bathrooms in good repair and water temperature was tested between 80.9 - 113.1 degrees F., which is not within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Laundry area was observed in good repair. A shaded table and chairs were observed in the backyard. Passageways and exit areas were observed free of obstructions. No large bodies of water were observed.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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 5
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: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043
VISIT DATE: 05/22/2025
NARRATIVE
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Garage has been transform into an accessory dwelling unit (ADU), with a room, kitchenette, and bathroom, where client #1(C1) is staying with a private caregiver.
Operational Requirements: Furniture is provided for outdoor recreation.
Staffing: Per roster there is a living staff and relief staff. Staff is available to provide supervision.
Personnel Records - Training: All staff records were available for review. Each staff has a criminal background clearance. Administrator certificate was observed for Carol Liess #60250973 exp. date: 2/25/27. HIV/TB training observed within the last 2 years. Five staff files were reviewed which include health screenings, TB test clearance, personnel records, finger clearance, and training.
Client Records - Incident Reports: All client records were available for review. Files were reviewed for 5 clients, which included medical assessments, admission agreement, individual service plan, and TB test.
Client Rights - Information: There are no clients using postural supports at the facility. A device with internet access is available.
Food Service: Facility has sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. There are no clients with modified diets.
Health-Related Services: Medication were observed centrally stored. A staff assist clients with medication and PRN medications. Staff have a current First Aid/CPR training on file and are responsible for contacting emergency services.
Incidental Medical Services: Facility does not currently serve any clients with restricted health conditions. LPAs reviewed files for client #1,#3, and #4 (C1,C3,C4) it was observed clients are over the age of 60.
Disaster Preparedness: Emergency Disaster Plan LIC610D (12/21) was observed and last reviewed on 5/24/24. Last emergency drill was conducted on 4/30/25, which are conducted monthly.
Emergency Intervention: N/A.

LPA interviewed 3 clients and 1 staff.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Katrin Silvestro and a copy of this report, LIC 809D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/22/2025 04:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/22/2025 at 03:43 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2025
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidence by:
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Administrator will submit a letter notifying the department of construction at facility, LIC 200, building permits, and sketch to the department by POC due date: 5/29/25.
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Based on observations and document review licensee did not notify the department of construction changing walls inside the home, and adding an ADU in the garage to have C1 there which poses a potential risk to the health, safety, or personal rights of the clients in care.
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Type B
05/29/2025
Section Cited
CCR80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care.... (1) Hot water temperature controls shall be maintained... not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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Administrator will adjust the water temperature and will maintain a daily water temperature log for 7 days and submitted to the department on POC due date: 5/29/25.
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Based on observation licensee did not ensure water temperature was within the requirement temperature of 105-120 degrees F., water temperature in bathroom #2 upstairs tested at 80.9 degrees F. which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/22/2025 04:59 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/22/2025 at 03:54 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION WILSON HOUSE
FACILITY NUMBER: 191221043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2025
Section Cited
CCR
80087(g)(1)

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80087 Buildings and Grounds: (g)... poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidence by:
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Administrator will provide training to staff regarding 80087 regulations and will submit a copy of training log to the department by POC due date: 5/23/25.
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Based on observation licensee did not ensure that staff maintain knives under lock, as a knife was observed in a cabinet accessible to the clients which poses an immediate risk to the health, safety, or personal rights for the persons in care.
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Type B
05/29/2025
Section Cited
CCR8

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85068.4 Acceptance and Retention Limitations: (g) If acceptance or retention of an individual 60 years of age or older... or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception...
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Administrator will submit an exception for any client over the age of 60 residing at the facility, with a family letter request, physician's report, and plan of care for each by POC due date 5/29/25.
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Based on document review licensee did not ensure to request an exception for clients over the age of 60, for client #1, #3,#4 which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mary G Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025


LIC809 (FAS) - (06/04)
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