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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606747
Report Date: 10/27/2025
Date Signed: 10/27/2025 11:08:35 AM

Document Has Been Signed on 10/27/2025 11:08 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:SAN DIMAS ADVENTIST HOME CAREFACILITY NUMBER:
197606747
ADMINISTRATOR/
DIRECTOR:		JASAIEL DE LEONFACILITY TYPE:
740
ADDRESS:1136 N. SAN DIMAS AVENUETELEPHONE:
(909) 971-9769
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 4DATE:
10/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Jasaiel De Leon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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LPA Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Gonzalez explained the purpose of the visit.

The facility is located on a main street in the city of San Dimas and is licensed to serve the elderly 60 and above, fire clearance for six (6) non- ambulatory, facility main retain one (1) hospice resident and has a dementia program.
The facility is a single story home consisting of a kitchen, dining area, living room, four (4) resident bedrooms and two (2) bathrooms, 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:
Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents, secured in the locked laundry room. LPA observed carbon monoxide detector in the hallway, was tested and is operable. Smoke detectors observed in the hallway and resident bedrooms, were tested and are operable. LPA inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA observed grab bars near toilets and inside showers. LPA observed no-slip flooring in showers. Showers were observed to be wheelchair accessible.
continued on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747
VISIT DATE: 10/27/2025
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Food Service: LPA observed sufficient supply of nonperishables for one (1) week and perishable foods for a minimum of two (2) days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean
Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed facility land line was operable.
Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Fire drills are conducted monthly, last drill 10/01/25. LPA observed facility sketches with exits and emergency exits routes throughout various locations of the facility.
Residents with Special Needs: No large bodies of water were observed. LPA observed signs posted indicating “No smoking - Oxygen in Use.” LPA observed an oxygen tank in resident room secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible.
Health Related Services/Incidental Medical Services: The medications are centrally stored, secured in ta kitchen cabinet inaccessible to residents in care. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.
Staffing: Administrator Certificate for Jasaiel De Leon expires 04/03/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA observed required annual training, CPR and First Aid for two (2) personnel records reviewed. LPA observed TB testing results, Health screening, fingerprint clearance and job application for personnel records reviewed.
Resident Records/Incident Reports: LPA reviewed files for four (4) residents in care. Resident files are maintained at the facility and contain the required documents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview held and a copy of this report was provided to Administrator Jasaiel De Leon.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
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