197606347-8-13-2026-28-AS-BGOZ-DWWVY5-20260813165035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606347
Report Date: 08/13/2026
Date Signed: 08/13/2026 04:50:56 PM

Document Has Been Signed on 08/13/2026 04:50 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:	COGSWELL GARDEN HOME		FACILITY NUMBER:	197606347
ADMINISTRATOR/ DIRECTOR:	LILIAN C. SALMORIN		FACILITY TYPE:	740
ADDRESS:	5405 N. COGSWELL ROAD		TELEPHONE:	(626) 444-3523
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY: 15		CENSUS: 7	DATE:	08/13/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Arni Castillo, Staff		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and reason for the visit was explained. Administrator was notified but unable to attend.

The facility is licensed to serve (15) elderly residents of which four (4) may be non-ambulatory, two non-ambulatory each in rooms 1 and 8. The facility is a single-story home located in a residential area of El Monte. The home consists of (8) resident bedrooms, one (1) staff room/office, (3) resident bathrooms, a living room, a dining area, a kitchen, a laundry room, a front yard, and a backyard.

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

The front and backyard are well maintained. There is a covered patio in the front yard with sufficient seating. Passageways and exits are free of obstruction.

The water temperature was tested in the bathrooms and measured within the required 105 degrees F - 120 degrees F. LPA observed grab bars and non-skid mats in showers.

Combination smoke/carbon monoxide detectors were observed by the kitchen and in the hallway, were tested and are operable. There were fire extinguishers throughout the home. Last emergency drill was conducted April 2026.

continued on LIC809C

Wei Siew Ho
Blanca Gonzalez
	DATE: 08/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

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 08/13/2026 04:50 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 08/13/2026 at 04:08 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: COGSWELL GARDEN HOME	FACILITY NUMBER: 197606347
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 7 resident files reviewed did not contain a medical assessment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2026
	Plan of Correction
1 2 3 4	Administrator will submit to LPA a medical assement completed by a physician which will include ambulatory status and TB clearance for R1 by POC due date.

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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC809 (FAS) - (06/04)

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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: COGSWELL GARDEN HOME	FACILITY NUMBER: 197606347
	VISIT DATE: 08/13/2026

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Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen cabinet and are inaccessible to residents. Cleaning supplies and disinfectants are locked in a cabinet outside and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Dining area and living room were observed to be clean and free of obstructions and have sufficient seating for residents in care.

Medications are centrally stored in a locked hall closet. Medications are documented properly and given as prescribed.

Resident bedrooms were observed to contain the required furniture which includes, for each resident, a bed, a chair, night stand, a lamp, or lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings. Hall closet contained extra, clean linens.

LPA reviewed (7) resident files. 6 out of 7 files were observed to contain required documentation. Facility file for R1 did not contain a medical assessment for review. Deficiency cited.

LPA reviewed four (4) staff files. Staff files were observed to contain required documentation including personnel record, fingerprint clearance, health screening with TB clearance, CPR/First aid certificate and continued education in-service trainings.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit were documented on the attached LIC809D.

Exit interview held and a copy of this report, LIC809D and appeal rights were provided to Arni Castillo, Staff.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC809 (FAS) - (06/04)

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