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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592693
Report Date: 05/02/2025
Date Signed: 05/02/2025 02:12:13 PM

Document Has Been Signed on 05/02/2025 02:12 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:UNITED CARE HOMESFACILITY NUMBER:
191592693
ADMINISTRATOR/
DIRECTOR:		JOCELYN TUBIANOSAFACILITY TYPE:
735
ADDRESS:702 LYONWOOD STREETTELEPHONE:
(909) 869-7754
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 6CENSUS: 6DATE:
05/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Tita Baluyut, Staff TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 5/2/25. LPA arrived unannounced and met with Staff, Tita Baluyut. The purpose of the visit was explained. The administrator, Jocelyn Tubianosa, arrived shortly after. The facility is licensed for (6) developmentally disabled clients, ages 18 - 59, of which 2 may be non-ambulatory in rooms #1 and #4. There are currently 6 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools.
The facility has 5 bedrooms (4 for clients and 1 for staff), 2 bathrooms, living room, kitchen, and an attached garage. Each client bedroom has the required furniture and lighting. There is a shaded area in the backyard for client use. There are no items obstructing the walkways and no pools. The smoke detectors are located in each bedroom and a carbon monoxide detector in the hallway. Knives and cleaning supplies are locked in the kitchen cabinet. Additional cleaning solutions are stored in the cabinet inside the garage. The hot water temperature is measured within the range of 105-120 degrees F. There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Facility provides internet access and clients have devices to use. There are no clients with a restricted health condition or using postural supports at this time. LPA reviewed 6 client files and all documents are in the file. The P&I ledger was reviewed as well. LPA reviewed 3 Staff and they have the required documents in their files. Medications are centrally locked and they are being administered as prescribed. Facility has the updated emergency disaster plan and conducting quarterly drills.
LPA issued a civil penalty today due to client being left at the home unsupervised during arrival. Staff returned home immediately after being called by the administrator and stated they went to purchase items from the store. An exit interview was held and a copy of this report was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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 05/02/2025 02:12 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/02/2025 at 01:53 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: UNITED CARE HOMES
FACILITY NUMBER: 191592693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1548(c)(3)
1548 Civil penalties; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(3) Absence of supervision, as required by statute or regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in which staff was not present while client #1 was at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2025
Plan of Correction
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The licensee shall ensure staff is present while client is at the facility. An in-service training shall be given to all staff and submit the log to LPA via email by POC due date.
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.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Cynthia D Chan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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