<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607831
Report Date: 12/09/2025
Date Signed: 12/09/2025 04:35:27 PM

Document Has Been Signed on 12/09/2025 04:35 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:MAUNA LOA OAKS "LLC"FACILITY NUMBER:
197607831
ADMINISTRATOR/
DIRECTOR:		LIUBOV SHEVTSOVAFACILITY TYPE:
740
ADDRESS:19041 E. MAUNA LOA AVE.TELEPHONE:
(626) 387-9186
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 3DATE:
12/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:16 PM
MET WITH:Adminstrator Liubov ShevtsovaTIME VISIT/
INSPECTION COMPLETED:
04:45 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
Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by Administrator Liubov Shevtsova and the purpose for the visit was explained.

The facility is licensed to serve six (6) elderly residents ages 60 and above, of which five (5) may be non-ambulatory, one (1) may be bedridden, and has a hospice waiver approved for three(3) residents.

The facility is a single-story home located in a residential area of Glendora. The home consists of a living room, dining area, kitchen, four (4) resident bedrooms, two (2) bathrooms, one (1) staff bedroom, a shaded patio in the backyard and an attached garage with laundry.

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

Physical Plant and Environmental Safety:

The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded area located in the backyard with sufficient seating for residents in care. Passageways and exits are free of obstructions.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
Document Has Been Signed on 12/09/2025 04:35 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 12/09/2025 at 03:57 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: MAUNA LOA OAKS "LLC"
FACILITY NUMBER: 197607831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 (3) residents, R1, did not have TB clearance on the Medical assessment or in the facility file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2025
Plan of Correction
1
2
3
4
Administrator agreed to obtain TB clearance for R1 and submit to LPA via email 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: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MAUNA LOA OAKS "LLC"
FACILITY NUMBER: 197607831
VISIT DATE: 12/09/2025
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
26
27
28
29
30
31
32
continued from LIC 809 (page 2)

The water temperature was tested in bathroom #1 in the hallway and measured 127.5 degrees F, which is above the required 105 degrees F - 120 degrees F. Bathroom #2 water temperature measured 126.1 degrees F. Administrator adjusted the water temperature at time of visit. LPA observed grab bars and non-skid mats.

Resident bedrooms all have required furniture which includes, for each resident, a bed, a chair, nightstand, and lights sufficient for reading. Resident beds have the required linen and linens were observed to be in good repair. There is closet storage space for clothing and other belongings. Hallway cabinet contained PPE supplies, surplus hygiene supplies and extra, clean linens.

Smoke detectors were observed throughout the facility and are operable. There is a carbon monoxide detector located in the kitchen, was tested and is operable. There are two (2) fire extinguishers located in the kitchen, and garage. Emergency drills conducted quarterly, last drill conducted 08/25/25.

All kitchen areas observed clean and free of litter, rodents, vermin and insects.


Kitchen appliances such as refrigerators, stove and microwave are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are secured, inaccessible to residents. Cleaning supplies and disinfectants are secured under the sink and are inaccessible to the residents and separate from food supply. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Containers storing waste are in good repair and free of leaks. Telephone service on the premises Dining area and living room are clean and free of obstructions and have sufficient seating for residents in care.

Attached garage has laundry area. Washing machine and dryer wear clean and operable at the time of visit. There is a cabinet with laundry supplies.

Staffing: Administrator and two (2) staff have current CPR training. Staffing sufficient in number and competent to meet resident need. LPA observed training logs for all staff.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MAUNA LOA OAKS "LLC"
FACILITY NUMBER: 197607831
VISIT DATE: 12/09/2025
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
26
27
28
29
30
31
32
page 3

Personnel Records- training: LPA reviewed files for three (3) staff. Personnel record maintained for each employee to contain the following: criminal record clearance, first aid/CPR, fingerprint clearance, personnel record, health screening, TB test

Residents Rights: Personal Rights are posted.

Planned Activities: LPA observed board games and books for resident use.

Resident Records/Incident Reports: LPA reviewed three (3) resident files. Each file contained admission agreement, recent medical assessment, ambulatory status, medical consent form, identification/face sheet, appraisal needs and service plan. File for R1 did not contain TB clearance, deficiency cited.

Medications are centrally stored in the secured in a locked kitchen cabinet. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report along with appeal rights were provided to the Administrator Liubov Shevtsova.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5