191222591-7-7-2025-28-AS-SMAN-DJD2JJ-20250707172625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 07/07/2025
Date Signed: 07/07/2025 05:26:37 PM

Document Has Been Signed on 07/07/2025 05:26 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-MADISON HOUSE		FACILITY NUMBER:	191222591
ADMINISTRATOR/ DIRECTOR:	CAROL LIESS		FACILITY TYPE:	735
ADDRESS:	489 N. MADISON AVENUE		TELEPHONE:	(626) 583-8019
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY: 9		CENSUS: 6	DATE:	07/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Imelda Jonson		TIME VISIT/ INSPECTION COMPLETED:	05:43 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 Analyst (LPA) Sakinah Madyun and Out of Class Licensing Program Manager (LPM) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Imelda Jonson and explained the reason for the visit. Facility is licensed to serve 9 ambulatory clients between the ages of 18-59 years old. Facility is a two story house with 5 client bedrooms, 2 client bathrooms, 1 downstairs live-in staff bedroom, 1 downstairs staff bathroom, living room, dining room, kitchen, an office area, detached garage, front and back porch with laundry room area, and 2 shaded outdoor sitting areas. 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 Imelda Jonson Facility Manager. Kitchen was observed clean. A knives and scissors were observed in a cabinet locked and inaccessible to the clients. The living room has a covered fireplace. LPA observed a total (5) client bedrooms, each was observed with sufficient lighting, bedding supplies, and furniture. LPA observed (2) bathrooms in good repair and water temperature was tested at 118.4 degrees F., which is 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. 2 shaded tables with chairs were observed in the backyard. Passageways and exit areas were observed free of obstruction. No large bodies of water were observed. Continue LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

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: HOMES FOR LIFE FOUNDATION-MADISON HOUSE	FACILITY NUMBER: 191222591
	VISIT DATE: 07/07/2025

NARRATIVE

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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 #7007795735 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 plans, 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. Kitchen freezer temperature observed at 18 degrees.
Health-Related Services: Medications were observed centrally stored but not locked and accessible to clients. 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.
Disaster Preparedness: Emergency Disaster Plan LIC610D (12/21) was observed and last reviewed on 5/31/25. Last emergency drill was conducted on 5/31/25, which are conducted monthly.
Emergency Intervention: N/A.

LPA interviewed 2 clients and 1 staff.

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

Exit interview was conducted with Imelda Jonson and a copy of this report, LIC 809D and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2025 05:26 PM - It Cannot Be Edited

Created By: Sakinah Madyun On 07/07/2025 at 04:52 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-MADISON HOUSE	FACILITY NUMBER: 191222591
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(1)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as staff's room was unlocked where medications are centrally stored and cabinets were observed unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2025
	Plan of Correction
1 2 3 4	Administrator will provide training on section 80075(k)(1) and will ensure staff are maintaining medication inaccessible to clients, a copy of the training will be submitted to the Department by POC due date 7/8/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:

	Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC809 (FAS) - (06/04)

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