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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608374
Report Date: 06/28/2026
Date Signed: 06/28/2026 03:26:13 PM

Document Has Been Signed on 06/28/2026 03:26 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:IN HONOR OF OUR PARENTS, INC.FACILITY NUMBER:
197608374
ADMINISTRATOR/
DIRECTOR:		ANGELA LOVEFACILITY TYPE:
740
ADDRESS:1317 W. 40TH PLACETELEPHONE:
(323) 296-7816
CITY:LOS ANGELESSTATE: CAZIP CODE:
90037
CAPACITY: 6CENSUS: 6DATE:
06/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:18 AM
MET WITH:Angela LoveTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Albertina Williams and explained reason for visit. Administrator Angela Love arrived shortly.

The facility is licensed to serve (6) elderly adults ages 60 and above, of which (6) can be non-ambulatory and (1) Bedridden in room #5. The facility has an approved hospice waiver for (1). Facility shall have awake staff 24/7. The facility is a single-story home located in a residential neighborhood. It consists of the following: five (5) resident rooms, two (2) bathrooms, living room, dining room, den, and kitchen, room in the attic upstairs for staff, and outside patio area with detached garage.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. Room #1 had a broken fire detector with wires exposed. LPA observed two bedrooms that had cameras and one of the residents’ bedrooms were being observed in living room. R5 had full bed rails with no physician order. Smoke detectors/carbon monoxide detectors were observed in rooms and throughout facility. The facility has two (2) fire extinguisher that are fully charged in kitchen and hall. LPA observed unlocked cabinet in laundry area with chemicals accessible to residents. Cleaning supplies, sharp objects, and toxic substances are locked in office. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. LPA observed a sufficient supply of 2-day perishable and a sufficient supply of 7 days non-perishable foods in the kitchen. There are no firearms or weapons stored at the facility The resident bathrooms have the required grabs, bars and non-skid mats. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. B1 had a reading of 140.9 and B2 128.4. The common areas, including the living room and dining area, have the required furniture. Boxes of diapers and other items need to be removed from living room. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents in back yard. LPA observed a clear plastic bin with cleaning items accessible to residents on the floor along with other items that need to be removed.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2026
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 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) Bathrooms hot water was above required temperature B1 140.0 B2 128.4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Administrator will adjust water in both bathrooms and sen LPA picture by POC due date 06/29/26.
Administrator will create a water log and test water for one week and send to LPA by 07/05/26.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in laundry area had unlocked cabinet with cleaning supplies and backyard had a clear bin full of cleaning supplies on floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Administrator will lock cabinet and remove items from backyard and conduct training with staff on section 87309(a) and send training with staff signatures by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(b)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above two (2) residents had cameras in bedrooms with one of the residents recording being displayed in living room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Administrator will remove cameras and send LPA pictures of both of them removed from bedrooms.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above two (2) residents had medication missing that was on medication list which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Administrator will obtain DC letters or provide LPA a picture of missing medication by POC due date.
R2-Lorazepam 0.5 mg 1 tab as needed, Trazodone Hydrochlor 50 mg 1 as needed. Had Dabigatran Etexilate 75 mg no order for it.
R5-Albuterol Sulfate and famotidine 10MG 1 tab as needed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above one resident had medication in box not given which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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LPA found a packet of 4 night time medications that were not given to R1 on 06/08/2026. Administrator will conduct staff training and send to LPA by POC due date.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above R5 had full bed rails with no order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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Administrator will obtain order or remove full bed rails by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above facility had expired INS which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will send valid INS to LPA by POC due date.
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
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Based on observation, the licensee did not comply with the section cited above bedroom #1 had a missing fire detector with wires exposed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will send LPA pictures of fixed detector.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in boxes of diapers and other items in lliving room area, and outside area had items on floor that needed to be removed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will send LPA pictures of removed items by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Administrator and two (2) staff did not have files at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will send LPA completed files by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 06/28/2026 03:26 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/28/2026 at 02:06 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above R6 did not have file at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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Administrator will send completed file for R6.
R1-current 602 and needs and service plan LIC 625.
R2-current 602 and needs and service plan LIC 625.
R3-Current 602 and needs and service plan 625.
R4- TB test and needs service plan./R5- current 602 and 625.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above facility had no drills at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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2
3
4
Administrator will conduct drills and send to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2026


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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IN HONOR OF OUR PARENTS, INC.
FACILITY NUMBER: 197608374
VISIT DATE: 06/28/2026
NARRATIVE
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Two staff files were reviewed and included Criminal clearance record, health screening with TB, and CPR/First Aid certificates. Administrator and two (2) staff did not have files at facility. Five (5) resident files were reviewed and were missing updated physicians reports and needs and service plans LIC 625. One residents file was missing. There were no drills conducted. Required liability insurance was expired. Three (3) resident medications were reviewed, and discrepancies were found. Medications are centrally stored in kitchen.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC 809D. Exit interview was held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2026
LIC809 (FAS) - (06/04)
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