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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222591
Report Date: 06/02/2026
Date Signed: 06/02/2026 04:36:02 PM

Document Has Been Signed on 06/02/2026 04:36 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 HOUSEFACILITY NUMBER:
191222591
ADMINISTRATOR/
DIRECTOR:		CAROL LIESSFACILITY TYPE:
735
ADDRESS:489 N. MADISON AVENUETELEPHONE:
(626) 583-8019
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 9CENSUS: 6DATE:
06/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Imelda Jonson, house managerTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Staff#2 (S2) house manager Imelda Jonson and spoke with Administrator Carol Liess over the phone. The reason for the visit was explained to them.

The facility is licensed to serve nine (9) mentally disabled, ambulatory adults, ages 18-59. The facility is a two-story house, located in a residential area in Pasadena. On the first floor, it consisted of a living room, dining room, kitchen, office, TV room, a laundry area, one (1) live-in staff room and one (1) staff bathroom. On the second floor, it consists of five (5) client bedrooms and two (2) clients’ bathrooms. The facility has a front yard and back yard, a detached garage and two (2) shaded outdoor sitting area.


The following CARE tool domains were reviewed during this visit:

Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance.

Physical Plant & Environment Safety: Physical plant tour was conducted on both floors. Clients’ bedrooms were toured and observed to be in compliance. Smoke detectors and carbon monoxide detectors on the second floor were dual and those detectors were separate devices on the first floor. They were operable. Fire extinguishers were mounted on the wall at the kitchen and office. They were fully charged. Hygiene products were available for clients. (-Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
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: HOMES FOR LIFE FOUNDATION-MADISON HOUSE
FACILITY NUMBER: 191222591
VISIT DATE: 06/02/2026
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Storage areas for cleaning solutions, toxins, knives, and hazardous items were locked and were inaccessible to clients. Water temperature was measured and were between 115.0 to 115.5 degrees F., which were in compliance with regulations. The backyard, outdoor and passageways were free of hazards.

Operational Requirements and Disaster Preparedness: Facility has an activity area / shaded areas furnished for outdoor use. Facility maintains documentation of the required emergency drills. Fire drills were conducted once every two months. The last fire drill was on 04/30/26.

Staffing and Personnel Records- Training: Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date of 02/25/2027. Annual fees are current.

Client Rights-Information and client Records-Incident Reports: Facility provided telephone landline and internet for the clients. Client rights posters and reporting posters were displayed within the facility.

Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one week (7) days of non-perishables food supply were observed.

Health Related Service: Medication was properly labeled, centrally stored, and in their original containers.

Exit:

No deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with House manager Imelda and LIC 809s were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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