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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605949
Report Date: 01/16/2026
Date Signed: 01/16/2026 04:03:04 PM

Document Has Been Signed on 01/16/2026 04:03 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RETREAT, THEFACILITY NUMBER:
197605949
ADMINISTRATOR/
DIRECTOR:		CLAUDIA ROMEROFACILITY TYPE:
740
ADDRESS:365 EL NIDO AVENUETELEPHONE:
(626) 356-2526
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 9CENSUS: 4DATE:
01/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Claudia Romero - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with Administrator and explained the purpose of the visit. During the visit, the CARE tool was used. The facility is licensed to serve 9 non ambulatory residents age 60 and above and has an approved Hospice waiver for 5 residents. Currently, there are four (4) residents in placement and 1 resident is in hospice care. Facility has a Dementia Program in place and a Food Service Waiver to prepare food off premises and transport to the facility.

The facility is a single home in a residential area, with a kitchen, living room, dining room, entry area, sun room area, 5 bedrooms 4 bathrooms, visitor's/staff bathroom, laundry area, a detached garage, front court, and a backyard area. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The front and backyard are well maintained. No pools and bodies of water on the premises. There is a shaded seating area for the residents located in the backyard. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. Sharps are locked and inaccessible to residents. Cleaning solutions and disinfectants was observed locked in the laundry room. The common areas are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. There is closet space for clothing and other belongings. Extra clean linen was observed in the hallway closet. Resident's rooms have the required furniture, bedding supplies and sufficient lighting. Bathrooms (4) in resident's rooms are in working condition, have grab bars, and skid mats. Water temperature was tested in each, between 114.1 - 117.1 degrees F.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RETREAT, THE
FACILITY NUMBER: 197605949
VISIT DATE: 01/16/2026
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Fireplaces located in living room and in 2 resident's rooms are covered. Emergency food supplies, water, and a generator were observed in the garage. Facility has a fire sprinkle system throughout. Fire extinguisher was observed at the facility fully charged. Carbon Monoxide detectors were observed operable. Auditory alarm devices to monitor exits were operable. Last fire drill was conducted on 10/17/2025. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Centrally stored medications are stored in a locked cabinet in the kitchen. LPA reviewed clients medications. Medications are documented properly and given as prescribed. LPA reviewed client's files and observed that all files are updated. LPA reviewed staff files confirmed staff working have fingerprint clearances.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
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