197803655-8-18-2026-28-AS-SVAD-DX3QHD-20260818121059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803655
Report Date: 08/18/2026
Date Signed: 08/18/2026 12:11:15 PM

Document Has Been Signed on 08/18/2026 12:11 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 PERPETUAL CARE		FACILITY NUMBER:	197803655
ADMINISTRATOR/ DIRECTOR:	LEAH ANGELA IGNACIO		FACILITY TYPE:	740
ADDRESS:	3027 WENWOOD ST.		TELEPHONE:	(909) 392-3482
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY: 6		CENSUS: 4	DATE:	08/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:47 AM
MET WITH:	Administrator, Leah Ignacio		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Vaid conducted an unannounced annual visit. LPA was met by Care giver Stephanie Mariano and explained the purpose of the visit. Administrator Leah Ignacio arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one zero (0) can be on hospice. The facility is a single-story home, located in a residential area. The home consists of a living room, (3) residents’ bedrooms, (1) live-in staff room, (1) room designated for licensee with (1) full bathroom inside the room, (1) resident bathroom, a kitchen, pantry, dining room, living room, detached garage, and shaded patio with seating in the backyard. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. All rooms are shared. There are extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. One carbon monoxide in the hallway is properly operating. One fully charged fire extinguisher which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients in kitchen pantry. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. It was observed that facility has a sufficient supply of 2 days perishable & 7 days non-perishable food deficiency cited. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms was measured between the required range of 105-120 degrees F. No swimming pool or bodies of water on the premises. There is a shaded seating area for the residents located in the backyard. Three (3) Staff files were reviewed and included Criminal clearance record, CPR/training health screening with TB. Administrator certificate pending. Four (4) Client files were reviewed and included physicians report, TB clearance.

Fernando Fierros
Sanjay Vaid
	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

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

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
	VISIT DATE: 08/18/2026

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Fire/earthquake drill was conducted 07/04/2026. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen. Medications were not reported on medical administration record, deficiency cited. LPA observed a hospital bed and mattress against wall next to shaded patio, deficiency cited. Administrator to provide liability insurance proof by 08/19/2026.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator Leah Ignacio.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2026 12:11 PM - It Cannot Be Edited

Created By: Sanjay Vaid On 08/18/2026 at 11:27 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: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways shall be kept free of obstruction. 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 LPA observed discarded bedding, chairs and matress in back yard near patio shaded area, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2026
	Plan of Correction
1 2 3 4	Administrator will clear the back yard of the matress, chairs and bedding. Send picture of cleared area and receipt of the pick-up.

Type B

Section Cited

CCR

87458(3)

(3) A record of current prescribed medication and an indication of whether the medication has been administered to the residents in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,and record review, the licensee did not comply with the section cited above the facility did not mark the medications on a medication administrator record (MAR)s which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2026
	Plan of Correction
1 2 3 4	Administrator will create and mark medications precribed to residents and send copy of MAR's by due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Sanjay Vaid
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC809 (FAS) - (06/04)

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