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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800817
Report Date: 11/10/2025
Date Signed: 11/10/2025 05:11:34 PM

Document Has Been Signed on 11/10/2025 05:11 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: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: 5DATE:
11/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Samuel SemeneaTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an announced Required-1 year visit using (CARE) Tools. LPA was met by Direct Support Professional Judith Espinoza and explained the purpose of the visit and toured the facility. Administrator Samuel Semenea was contacted by phone and arrived shortly after. The facility is licensed to serve developmentally disabled clients between the ages of 18 to 59 and receive services from South Central Regional Center. LPA utilized the (CARE) tools for the visit today and observed the following:

Infection Control: Staff are adhering to Infection Control requirements. Infection Control practices and Personal Protective Equipment (PPEs) were maintained. Staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted an Infection Control Plan updated and revised 10/2/2025.

Physical Plant/Environment Safety: The facility is a single home, and it is located within a residential neighborhood. There are six (6) client bedrooms, two (2) living room/common areas, two (2) bathrooms, a kitchen, dining area and storage room. A detached garage was observed which consists of a laundry area with washer and dryer observed to be in operating condition. The front and backyard was observed to be well maintained and there are no pools or large bodies of water. A shaded area located on the front porch and backyard patio is available and accessible for the clients. Passageways and exits are free of obstruction and debris. Cleaning supplies and toxic substances are inaccessible to clients. The water temperature was tested and was within the required regulation of 105 - 120 degrees Fahrenheit. The 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 tested operable during the visit. There are no firearms or weapons stored at the facility. There is one fire extinguisher in the dining area observed to be charged and last inspected 06/16/2025. *****REPORT CONTINUED ON LIC809C*****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2025
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: HOME OF (TLC)
FACILITY NUMBER: 197800817
VISIT DATE: 11/10/2025
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 Personnel Records/Staff Training: LPA reviewed files for eight (8) of eight (8) staff and conducted two (2) of eight (8) available staff interviews. A total of eight (8) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and proof of staff training, Health screening, First Aid/CPR/AED, fingerprint clearance, and background check clearance, and training are current.

Client Records-Incident Reports: LPA reviewed files for six (6) of six (6) clients. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Personal Property and Clients Personal Rights observed.

Client Rights-Information: Client personal rights are posted. Per Administrator the facility provides internet and landline phone services to all clients. LPA interviewed five (5) of five (5) clients.

Food Service: LPA observed an adequate supply of 2 days perishable and 7 days Non-perishable. Sanitation practices and kitchen cleanliness was observed. Pesticides and cleaning supplies are kept away from the food preparation areas.

Health Related Services: Medications are administered by staff daily and documented. LPA observed a first aid kit fully stocked and locked in medication cabinet inaccessible to clients in care.

Incidental Medical Services: None of the clients at this facility have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency and Disaster Plan updated and revised 09/03/2025.

Emergency Intervention: Staff have emergency intervention training monthly last conducted 06/25/2025.

Technical Violation issued see LIC9102 . Exit interview and a copy of this report was provided to Administrator Samuel Semenea.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC809 (FAS) - (06/04)
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