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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191593069
Report Date: 03/17/2026
Date Signed: 03/17/2026 05:15:37 PM

Document Has Been Signed on 03/17/2026 05:15 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:DELLA HIGGINS HOMEFACILITY NUMBER:
191593069
ADMINISTRATOR/
DIRECTOR:		HIGGINS, DELLAFACILITY TYPE:
735
ADDRESS:1105 OXFORD PLACETELEPHONE:
(909) 623-0555
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 2DATE:
03/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Della Higgins - Licensee/Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required-1 year visit. LPA was met by Della Higgins, licensee/administrator and explained the purpose of the visit. The facility is licensed to serve (4) adults age range 18 through 59, (2) non ambulatory in bedroom #1. The home is vendorized through San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Staff are adhering to infection control requirements. The facility is a single story home in a residential area, consists of (4) bedrooms, of which (2) are shared client bedrooms and (2) staff rooms, (2) bathrooms, living room, dining area, kitchen, enclosed patio, backyard and detached garage. There are (2) clients residing in the home. Client bedrooms were toured and have sufficient storage space and lighting. Cleaning solutions and disinfectants are locked and inaccessible to clients. LPA observed the kitchen knives store in an unlocked kitchen cabinet. Smoke detectors and carbon monoxide combo detectors were tested and operable. No security window bars installed. Facility has working telephone service. Water temperature readings are within the required 105 - 120 degrees Fahrenheit. There are no pools or large bodies of water. The outdoor activity area in the backyard provides a shaded area.
A total of (2) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is valid and expires on 06/08/2026. Administrator has valid HIV/AIDS Training certificate, completed on April 25, 2025. LPA reviewed staff files. Proof of staff training, health clearance, and vaccinations are current. However, first aid/CPR training certificates for both staff expired on 02/27/2026.

*****Refer to LIC 809C for the continuation of this report. *****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2026
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: DELLA HIGGINS HOME
FACILITY NUMBER: 191593069
VISIT DATE: 03/17/2026
NARRATIVE
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Client personal rights are posted. Facility provides internet service and phone to the clients. LPA reviewed (2) client files. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent for Medical Treatment, Client Personal Property and Clients Personal Rights observed for client #1 but client #2's files were incomplete.

There are sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. Pesticides and cleaning supplies are kept away from the food preparation areas.

LPA reviewed medication for all clients. The medications are centrally stored and are bubble packed. Medications are labeled and are maintained in compliance with label instructions. The facility does not use a Medication Administration Record (MAR) to document medications given as they are only administering medication for client #1. There are no clients at this home with incidental medical services nor have a restricted health condition. The facility has completed the Emergency Disaster and Mass Casualty Plan, however the information has not been updated. The information for the temporary shelter locations such as telephone numbers are invalid.

Deficiencies cited. Technical violations issued. Exit interview conducted and a copy of this report was provided to Della Higgins, Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/17/2026 05:15 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2026 at 02:48 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: DELLA HIGGINS HOME
FACILITY NUMBER: 191593069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, 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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that knives were stored in an unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 03/18/2026
Plan of Correction
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***DEFICIENCY CLEARED DURING THE VISIT.***
Administrator kept the knives in a locked cabinet immediately.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2026 05:15 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2026 at 02:48 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: DELLA HIGGINS HOME
FACILITY NUMBER: 191593069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Administrator and staff did not have a valid first aid/CPR training, expired on 02/27/2026 which poses/posed a potential health, safety personal rights risk to clients in care.
POC Due Date: 03/27/2026
Plan of Correction
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Administrator will send a copy of the first aid/CPR training registration schedule to LPA/CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
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