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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802685
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:38:37 PM

Document Has Been Signed on 05/10/2022 03:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MONTEREY PARK HOMEFACILITY NUMBER:
197802685
ADMINISTRATOR:HIRAM OWEN MASAYONFACILITY TYPE:
735
ADDRESS:1539 FELIZ STTELEPHONE:
(626) 289-8701
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 6DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marietta Beza, house leadTIME COMPLETED:
03:45 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 Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA was allowed entry by house lead staff and explained the purpose of the visit. Administrator, Owen Masayon, arrived shortly thereafter to assist with the visit. The facility is licensed for 6 developmentally disabled adults aged 18 through 59 for ambulatory status only. There are currently six ambulatory clients in placement by East Los Angeles Regional Center.

LPA Chan toured the facility with the Administrator. The facility has 4 bedrooms, 2 bathrooms, open living room, dining room, with kitchen area, and office space. There are no items obstructing the walkways. LPA observed proper signage posted throughout the home. The facility keeps a log documenting the daily temperature of staff and clients. There are at least 30 days of PPE supplies stored in the garage. The bathrooms have lid covering trash bins and paper towels. LPA observed at least 2 days of perishables and a week of non-perishable food items. The hot water temperature was measured between 105-120 degrees Fahrenheit. The medication was reviewed for 4 clients and are being administered as prescribed by the physician.
Per Administrator, staff meetings are held often to provide updates on CCL or LA County of Public Health guidance. The facility is continuing to follow their mitigation plan and the strictest guidance.

There are no deficiencies observed during today's visit.
An exit interview was conducted with the Administrator and a copy of this report was given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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 1