197802108-5-11-2026-28-AS-ALOZ-DTYQX2-20260511123250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802108
Report Date: 05/11/2026
Date Signed: 05/11/2026 12:33:18 PM

Document Has Been Signed on 05/11/2026 12:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197802108
ADMINISTRATOR/ DIRECTOR:	SIOKKHING SMITH		FACILITY TYPE:	735
ADDRESS:	500 S. MCPHERRIN AVE		TELEPHONE:	(626) 307-8896
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91754
CAPACITY: 6		CENSUS: 5	DATE:	05/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:59 AM
MET WITH:	In H. Lim, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA was greeted by In Lim, Administrator and assisted with the visit. LPA explained the purpose of the visit.

The facility is licensed to serve 6 ambulatory and developmentally disabled clients aged 18 to 59. Currently, there are five (5) clients in placement. One (1) client are over 60 years of age. All clients are provided with Case Management services by East Los Angeles Regional center.

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves. while assisting clients. Staff are disinfecting often for high-tooth surfaces. Facility has sufficient PPE supplies, an Infection Control Plan was misplaced. Bathrooms have hand washing signs, soap and paper towels. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Fire Drills are conducted every six months; the last fire drill was conducted on 12/06/2025 Emergency Disaster/ Earthquake Drills are conducted every 6 months, and the last one was conducted on 12/06/2025. Drills are required to be conducted quarterly.

Physical Plant & Environment Safety: The facility has 4 client bedrooms, including 2 shared rooms, 2 bathrooms, additional bedroom with bathroom designated as an isolation room, living room, dining room, kitchen, an attached garage. and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within CCL regulations.

LIC 809C for continuation of report.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802108
	VISIT DATE: 05/11/2026

NARRATIVE

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(continued from 809)

Toilets and water faucets worked properly. Bathroom sinks and showers were free of mold/mildew. LPA observed that sufficient toiletries are accessible to clients. Water temperature measured 128.5 – 130.3 degrees F which is not within range of 105.0 – 120.0 F. Facility temperature was comfortable. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors were complying and operational. No firearms are stored at facility, and no bodies of water are present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. One exit door outside was jammed shut and need adjustment, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, facility sketch, visitor policy, complaint procedures, menu, and emergency disaster plan.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18, are fingerprinted and cleared and associated with the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Administrator, and S1-3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting. Administrator certificate expires 10/30/2026.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility clients.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7-day supply of non-perishable items. The food is properly stored in the refrigerator, which is clean and well maintained. There are no clients with special diets residing at this facility. Facility kitchen area is kept clean and free from rodents and other bugs/insects. Plates, cups, and utensils are kept clean and stored properly.

(continued on 809c)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802108
	VISIT DATE: 05/11/2026

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(continued from 809C)

Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights. Physician's Report for the Elderly LIC602a is on file for 1 client over 60 years of age.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for 4 clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services or restricted health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted. Plan needs to be revised to include one shelter away from facility.

Emergency Intervention: Not Applicable.

Deficiency noted. Technical Advisories issued. Civil penalties issued for repeat violation. Exit interview and a copy of this report, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/11/2026 12:33 PM - It Cannot Be Edited

Created By: Alberto Lopez On 05/11/2026 at 12:04 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: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197802108
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. water temperature measure 128.5 - 130.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2026
	Plan of Correction
1 2 3 4	Administrator will keep temperature log for 3 days and send proof to LPA.

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.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC809 (FAS) - (06/04)

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