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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800817
Report Date: 01/23/2025
Date Signed: 01/28/2025 08:25:12 AM

Document Has Been Signed on 01/28/2025 08:25 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:HOME OF (TLC)FACILITY NUMBER:
197800817
ADMINISTRATOR/
DIRECTOR:		SEMENEA, SAMUELFACILITY TYPE:
735
ADDRESS:12159 JULIUS AVE.TELEPHONE:
(562) 928-7009
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 6DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Roxana Reyes, Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
05:15 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 Analysts (LPAs), Mayra Cota and Luis De Leon, conducted an unannounced annual visit using the Care Inspection Evaluation Tool (CARE). LPAs met with Georgeta Georgescu, Direct Support Staff and Administrator Samuel Semenea arrived thereafter and assisted with the visit and the tour of the facility. The reason for the visit was explained. The physical plant was inspected along with client/staff records, food supply and medication. The facility is licensed to serve developmentally disabled clients between the ages of 18 to 59 and receive services from South Central Regional Center. Three (3) clients were attending Day Program, and three (3) clients were present at the time of the visit.

The facility is a single home, and it is located within a residential neighborhood. LPAs and Administrator toured the home and inspected the following: six client bedrooms, two living rooms, two bathrooms, kitchen, dining area and storage room. A detached garage was observed which consists of a laundry area. Washer and dryer were observed to be in operating condition. The outdoor environment which consists of a front and backyard was observed to be well maintained and there are no pools or large bodies of water. A shaded area located in the front and back patio is available and accessible for the clients. Passageways and exits are free of obstruction. The water temperature was tested and was within the required regulation of 105 - 120 degrees F. Client bedrooms have the required furniture such as bed frames, dressers, adequate lighting, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Smoke and carbon monoxide detectors were observed throughout the facility and were tested and operable during the visit. There is one fire extinguisher in the dining area which was observed to be charged.

***Continued on LIC 809-C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 3
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: HOME OF (TLC)
FACILITY NUMBER: 197800817
VISIT DATE: 01/23/2025
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
The kitchen was observed to be clean and operable for food preparation. Kitchen appliances were observed to be functional and clean. Sharps were observed to be locked and are inaccessible to clients. Cleaning supplies and toxins are locked in the storage room and are inaccessible to clients. Medications are centrally stored and locked in the medication cabinet. LPAs observed at the time of visit one staff (Staff #1) has not obtained a criminal record clearance.

Deficiency is being cited. See LIC 809D.

Exit interview was conducted with the Assistant Administrator, Samuel Semenea. A copy of the report, appeal rights was issued.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/28/2025 08:25 AM - It Cannot Be Edited


Created By: Mayra Cota On 01/23/2025 at 04:17 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: HOME OF (TLC)
FACILITY NUMBER: 197800817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019(e)(2)
Criminal Record Clearance. All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review of the LIC 500 and LIS Faciltiy Personnel Report Summary staff #1 (S1) is not cleared to work at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
1
2
3
4
The LIcensee will ensure that all indiviaduals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility properly obtain criminal record clearance. LIcensee agrees to allow Staff #1 to resume work after fingerprint and Livescan clears.
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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3