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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603784
Report Date: 04/01/2026
Date Signed: 04/01/2026 11:50:39 AM

Document Has Been Signed on 04/01/2026 11:50 AM - 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:FAITH MANORFACILITY NUMBER:
197603784
ADMINISTRATOR/
DIRECTOR:		CLAREL MARTINEFACILITY TYPE:
735
ADDRESS:1832 SOUTH ARLINGTON AVE.TELEPHONE:
(323) 737-2310
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 21CENSUS: 13DATE:
04/01/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Clarel MartineTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis De Leon conducted a case management visit regarding Health and Safety Check visit. LPA met with Administrator Clarel Martine and explained the purpose of the visit.

During the physical plant tour, LPA observed construction work being done on the second-floor bathroom that had previously been observed to have a leak causing mold on the first-floor ceiling, right under the second-floor bathroom. LPA requested Administrator for a project bathroom remodeling plan and incident report to inform CCLD of remodeling project. The administrator stated that an incident report had not been filed with licensing. LPA observed construction debris in the hallway and backyard which may pose a health and safety risk to clients in care. LPA requested Administrator to submit a project plan including duration of the project, details of project, mitigation measures taken to care for clients’ safety including ADLs support provided to clients while project is ongoing. Administrator should include in the project plan the building permits needed for the project or a statement indicating that no permits are needed for the remodeling project. A deficiency is cited.

The following items were requested during the visit today:
· Facility plan for the construction project

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC 809D, and Appeal Rights were discussed and provided to Administrator Clarel Martine.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2026
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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Document Has Been Signed on 04/01/2026 11:50 AM - It Cannot Be Edited


Created By: Luis DeLeon On 04/01/2026 at 11:23 AM
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: FAITH MANOR
FACILITY NUMBER: 197603784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2026
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the
proposed change.

This requirement is not met as evidenced by:
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Licensee shall submit a project plan indicating project duration, project details, and facility measures to care for clients' health and safety, including ADLs support. The project plan shall be submitted to CCLD by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in bathroom construction remodeling on second-floor bathroom where licensee did not notify licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
04/06/2026
Section Cited
CCR80086(c)

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80086 Alterations to Existing Building or New Facilities (c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.

This requirement is not met as evidenced by:
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Licensee shall submit a project plan including building permits for remodeling project. The project plan shall be submitted to CCLD by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in bathroom construction remodeling on second-floor bathroom where licensee did secure a building permit prior to remodeling which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2026


LIC809 (FAS) - (06/04)
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