197801816-1-5-2026-28-AS-BGOZ-DQ2QZD-20260105113634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801816
Report Date: 01/05/2026
Date Signed: 01/05/2026 11:36:47 AM

Document Has Been Signed on 01/05/2026 11:36 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:	MSJI HOME INC		FACILITY NUMBER:	197801816
ADMINISTRATOR/ DIRECTOR:	INDIRA BHAVSAR		FACILITY TYPE:	735
ADDRESS:	1324 JUANITA AVE		TELEPHONE:	(909) 592-6003
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY: 6		CENSUS: 4	DATE:	01/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:54 AM
MET WITH:	Administrator Indira Bhavsar		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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 staff, and the purpose of the visit was explained. Administrator Indira Bhavsar arrived shortly after. Facility is licensed to serve (6) developmentally disabled adults, ages 18-59. One (1) may be non-ambulatory. The facility is a one-story family home located in a residential area of San Dimas. The home consists of a living room, dining area, kitchen, three (3) client bedrooms, two (2) bathrooms, laundry room, front yard, backyard, and attached garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Cleaning supplies and toxic substances are inaccessible locked in cupboards in hallway. There are no firearms or weapons stored at the facility. Kitchen was observed clean and free of pests. LPA observed sufficient supply of nonperishable food for one week and perishable foods for a minimum of two days. Soaps, detergents, and cleaning supplies were observed to be stored away from food supplies. Freezer were observed to be clean and within temperatures of 0-degree F and refrigerator with maximum temperature of 40-degree F. continued on LIC 809

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

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 01/05/2026 11:36 AM - It Cannot Be Edited

Created By: Blanca Gonzalez On 01/05/2026 at 10:59 AM

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: MSJI HOME INC	FACILITY NUMBER: 197801816
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

85068.4(g) Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients… the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 4 Clients are over the age of 60 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2026
	Plan of Correction
1 2 3 4	Licensee agrees to obtain and submit required documents to request an age exception from CCL 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: 01/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MSJI HOME INC	FACILITY NUMBER: 197801816
	VISIT DATE: 01/05/2026

NARRATIVE

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continued fron LIC 809
LPA inspected three (3) client bedrooms. All client bedrooms contained required furniture, linens and lighting. Linens were observed clean and in good repair. Water temperature in bathrooms measured at 105 degrees F and 105.2, which is within the required 105 degrees F - 120 degrees F.

Combination smoke and carbon monoxide detectors observed throughout the facility were tested and are operable. Fire extinguisher was observed by the kitchen and was last serviced 09/16/2025. Emergency drills conducted monthly, last drill completed 012/12/25.

Centrally stored medications were observed secured in a locked hallway closet. The facility uses the Medication Administration Record (MAR) log to document medications given.

Washing machine and dryer wear clean and operable at the time of visit.
There are no pools or large bodies of water. There is a covered patio located in the backyard with sufficient seating for clients in care. Passageways and exits are free of obstructions.

Four (4) client files were reviewed. 2 out of 4 clients in care are over the age of 60. Deficiency cited. Three (3) staff files were reviewed and were observed to contain required documentation.

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

Exit interview held and a copy of this report along with appeal rights were provided to the Administrator Indira Bhavsar.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

LIC809 (FAS) - (06/04)

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