197607735-7-2-2026-11-AS-SLEO-DVLU7B-20260702151941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607735
Report Date: 07/02/2026
Date Signed: 07/02/2026 03:20:00 PM

Document Has Been Signed on 07/02/2026 03:20 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	4219 W. 162ND STREET HOME		FACILITY NUMBER:	197607735
ADMINISTRATOR/ DIRECTOR:	MELANIE M ESTEPA		FACILITY TYPE:	740
ADDRESS:	4219 W. 162ND STREET		TELEPHONE:	(424) 247-8936
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 3		CENSUS: 3	DATE:	07/02/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:10 AM
MET WITH:	Administrator - Princess Lyn Bueno Usi		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	On 07/02/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Princess Lyn Bueno Usi. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 3 non-ambulatory adults ages 60 and above. A total of 3 residents are currently residing in this facility. The Annual Licensing Fees are current. Facility Layout: The facility is a one-story house located in a residential street. The home consists of 3 resident bedrooms; 2 full bathrooms; 1 great room which consist of an office space, living room area, dining room area, and kitchen; 1 detached garage divided by two rooms – 1 small laundry room and 1 large garage room; and a backyard patio area. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there were no security bars or weapons on the premises.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

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 07/02/2026 03:20 PM - It Cannot Be Edited

Created By: Socorro Leandro On 07/02/2026 at 02:23 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having: food of good quality; bathroom faucet being in disrepair; kitchen cabinet being in disrepair; 2 kitchen burners being in disrepair; dust/grease built up on kitchen vent and kitchen cabinet knobs; mold on garage door; and rust on washer machine which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2026
	Plan of Correction
1 2 3 4	The Administrator has agreed to fix said above items and email pictures to Socorro.Leandro@dss.ca.gov The Administrator has agreed to create a plan to maintain facility in good repair and maintain food items in good quality and email plan to Socorro.Leandro@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.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 07/02/2026

NARRATIVE

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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is a fire extinguisher in the kitchen area and it was last serviced on 06/17/2026. There are two landline telephones on the kitchen counter-tops. There were food items that were not of good quality and had passed best by dates. Two kitchen burners were difficult to turn on. A kitchen cabinet is in disrepair. There is dust and grease built up on the kitchen vent, on top of the refrigerator, and on the cabinet knobs.

Great Room: There is a landline telephone and videoconferencing device in the office area. There are games and activity supplies for residents in the living room area.

Resident Bedrooms: 3 out of 3 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Each room has toiletry supplies, clean linens, towels, and a locked storage are for medicine.

Bathrooms: Toilets, showers, and grab bars were secure. Adequate lighting and toiletries were accessible to residents. One bathroom faucet was in disrepair. The hot water temperature measured 113.6 Fahrenheit.

Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 3 out of 3 Medication Administration Records (MARs) were reviewed and they were current and up to date.

Garage: The laundry room has a washer and dryer, cleaning supplies, incontinent supplies, holiday décor supplies, and a file cabinet with old files. The large garage room has extra/emergency food supply, refrigerator, extra cleaning supplies, and other facility supplies.

Miscellaneous: Documents are posted as mandated. Last emergency disaster drill was conducted on 07/01/2026. The Certificate of Liability Insurance expiration date is 08/06/2025. The Surety Bond next renewal date is 03/12/2029. The facility has an Infection Control Plan and Emergency Disaster Plan. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: 4219 W. 162ND STREET HOME	FACILITY NUMBER: 197607735
	VISIT DATE: 07/02/2026

NARRATIVE

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3 resident records were reviewed. 2 out of 3 resident records did not have a doctor’s order for half bed rails. 2 out of 3 residents did not have an updated IPP/ANS on file but did have a recent ISP.

A technical advisor is being provided regarding maintaining IPP/ANS plans up to date.

A technical violation is being provided regarding having doctor’s orders for postural supports.

A deficiency is being cited based on observation review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Princess Lyn Bueno Usi.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026

LIC809 (FAS) - (06/04)

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