<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603739
Report Date: 10/20/2025
Date Signed: 10/20/2025 04:28:54 PM

Document Has Been Signed on 10/20/2025 04:28 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:MENTONE HOUSEFACILITY NUMBER:
197603739
ADMINISTRATOR/
DIRECTOR:		ROBIN PHILLIPSFACILITY TYPE:
735
ADDRESS:1980 MENTONETELEPHONE:
(626) 398-5629
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
10/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Greg Tillman, StaffTIME VISIT/
INSPECTION COMPLETED:
04:35 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) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA arrived at the facility at 12:45pm and rang the doorbell but no one answered. LPA called the Staff, Gregory Tillman, who said on arriving in a few minutes. At 1:05pm, LPA met with staff, Gregory Tillman and Ana Rodrigurez, DSP and explained the purpose of today's visit. The facility is approved to serve developmentally disabled clients ages 18 through 59 years, ambulatory only.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is in place. The facility has a valid Liability Insurance policy in place. Surety Bond is valid. Last Fire Drill was conducted on 10/15/2025.

Physical Plant & Environment Safety: This facility is a single-story home consists of kitchen, dining room, living room, (4) client bedrooms, (2) bathrooms, den/activity area, laundry area, detached garage and a backyard. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bed and furnishings are in good working condition. Extra towels and linens are kept in the hallway closet. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen. The fire extinguisher in the kitchen was recently inspected on 07/15/2025. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Fireplace is closed and inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2025
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 7
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)
Page: 2 of 7
Document Has Been Signed on 10/20/2025 04:28 PM - It Cannot Be Edited


Created By: Daniel Konishi On 10/20/2025 at 04:01 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: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observed Administrator’s file did not have a valid HIV and TB training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
1
2
3
4
Administrator will send a valid HIV and TB training certificate to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observed that the Administrator's file did not have a completed health screening with TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
1
2
3
4
Administrator will send the Administrator's completed health screening including TB clearance to the LPA by the POC due date. Daniel.Konishi@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/20/2025 04:28 PM - It Cannot Be Edited


Created By: Daniel Konishi On 10/20/2025 at 04:01 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: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025

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
1
2
3
4
Based on record review, LPA reviewed Staff #2 (S2) and Staff #3 (S3’s) file did not have valid First Aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
1
2
3
4
Administrator will send Staff #2 (S2) and Staff #3 (S3's) valid First Aid Training to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observed Client #1 (C1’s) file did not have a Admissions Agreement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
1
2
3
4
Administrator will send Client #1 (C1's) Admissions Agreement to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/20/2025 04:28 PM - It Cannot Be Edited


Created By: Daniel Konishi On 10/20/2025 at 04:01 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: MENTONE HOUSE
FACILITY NUMBER: 197603739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA also observed Client #4 (C4’s) file did not have a complete medical assessment with a TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
1
2
3
4
Administrator will send Client #4 (C4's) completed medical assessment or completed physician's report with a TB clearance to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
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: MENTONE HOUSE
FACILITY NUMBER: 197603739
VISIT DATE: 10/20/2025
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
26
27
28
29
30
31
32
Physical Plant & Environment Safety [Cont.]: There are no firearms or weapons stored at the facility. Water temperature readings measured between 110.8 to 111.7 which is within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area.

Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records-Training: LPA reviewed four (4) staff files that include: personnel record, staff training, health clearance, employee rights, and 1st Aid/CPR/AED training. Administrator certificate is valid and expires on 10/15/2027. However, LPA observed Administrator’s file did not have a valid HIV and TB training and a completed Health Screening including TB clearance. LPA also reviewed Staff #2 (S2) and Staff #3 (S3’s) file did not have valid First Aid training.

Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the client.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with modified diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept clean and stored properly.

Client Records-Incident Reports: LPA reviewed four (4) client files which includes Face Sheet, Admission Agreement, Physician's Report (including TB and Ambulatory Status), Individual Program Plan (IPP), Behavior Intervention Plan, and Clients Personal Rights. However, LPA observed Client #1 (C1’s) file did not have a Admissions Agreement. LPA also observed Client #4 (C4’s) file did not have a complete medical assessment with a TB clearance.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed four (4) clients’ medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. LPA observed Physician’s Orders and Central Stored Medication Destruction Record in file. LPA observed no issues.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: MENTONE HOUSE
FACILITY NUMBER: 197603739
VISIT DATE: 10/20/2025
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
26
27
28
29
30
31
32
Incidental Medical Services: Per Administrator, there is one (1) client at this home with a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. The last fire/earthquake drill was conducted on 10/15/2025.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the DSP, Ana Rodriguez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC809 (FAS) - (06/04)
Page: 7 of 7