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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204621
Report Date: 05/13/2026
Date Signed: 05/13/2026 04:10:42 PM

Document Has Been Signed on 05/13/2026 04:10 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SEDONA GUEST HOMEFACILITY NUMBER:
198204621
ADMINISTRATOR/
DIRECTOR:		ANTONIO ARBOLEDAFACILITY TYPE:
740
ADDRESS:21635 HOWARD STREETTELEPHONE:
(310) 792-9020
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 5DATE:
05/13/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Caregiver - Nicanor SantosTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 05/13/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted a continuation unannounced Required – 1 Year Inspection to the above-named facility Caregiver, Nicanor Santos. The purpose of the visit was explained, and the LPA was allowed entry to the facility.

This facility is licensed to serve 6 nonambulatory adults ages 60 and above, of which 6 may be on hospice.

A total of 5 residents are currently residing in this facility.

The Annual Licensing Fees are current.

The following was observed on 05/12/2026:

Facility Layout: does not match the facility sketch that was submitted to the department. The facility has two additional staff rooms in the garage. The facility is a one-story house located on a residential street. The home consists of 6 resident bedrooms; 4 full bathrooms; 2 staff bedrooms; garage/laundry room; great room which includes the kitchen area, dining room area, living room area; and an outdoor patio area.

Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there were no security bars or weapons on the premises.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2026
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 10
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 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the kitchen vent pipe and sink are in disrepair, kitchen vent filters are missing, underneath the kitchen sink there was water damage and the walls/wood are crumbling, kitchen cabinets need to be deep cleaned to remove dead vermin, dust, grease which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit pictures for proof of correction to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee has not updated their facility sketch to match the facility’s physical plant, the garage has 2 staff bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licesee will email updated facility sketch to Socorro.Leandro@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having cleaning solutions and medications (the garage/laundry room was unlocked and the cleaning solutions were out) accessible to resident in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and trainings to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not maintaining complete and current personnel records in the facility, Staff 1 (S1) to Staff 4 (S4) had incomplete records ranging from mandatory trainings, CPR/First Aid Certificates, Job Application/Personnel Record, Health Screening Report, TB Test, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and proof of complete personnel records to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having dead and live vermin in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and proof of correction which include but not limited to cleaning schedules, pictures of all kitchen cabinets, amount of times exterminators have serviced the facility, their records and their advice to the facility email proof to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in keeping unlocked medication in resident rooms while their Medical Assessments indicate that they are unable to manage medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and trainings to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not maintaining medication in its original container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and trainings to Socorro.Leandro@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not documenting the time medication was taken and the residents’ response which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and trainings to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having PRN medication without an order from the physician on a prescription which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan, order of the physician and trainings to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 05/13/2026 04:10 PM - It Cannot Be Edited


Created By: Socorro Leandro On 05/13/2026 at 11:26 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in not maintaining complete and current resident records, Resident 1 (R1) to Resident (5) had incomplete records ranging from incomplete Admission Agreements and I.D. And Emergency Information, not having TB Test record and Personal Rights, not having current Medical Assessment and Appraisal & Needs Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee has agreed to create a plan to address said issues and submit plan and email complete and current resident record (R1-R5) to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Resident 2 (R2) is administering their own injections even though their Physicians Report (Medical Assessment) dated 05/21/2019 indicates that they cannot manage their own medications due to poor hand function which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2026
Plan of Correction
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The Licensee will start to solve this issue with updating R2’s Medical Assessment and verify if R2 can perform their own injections. (If resident has Dementia/Mild Cognitive Impairment/hand mobility issues the caregivers cannot perform hand-over-hand assistance a skilled professional will have to perform injections). Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621
VISIT DATE: 05/13/2026
NARRATIVE
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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. There is fire extinguisher in the kitchen area, and it was last serviced on 05/01/2026. There were live and dead vermin observed in the kitchen and kitchen cabinets. The kitchen vent was in disrepair and did not have filters. The kitchen sink is in disrepair (it is rusty). Underneath the kitchen sink inside the cabinet there was a lot of water damage, and the walls were in disrepair as well as the cabinet.

Great Room: There is a videoconferencing device and games/activity work for residents.

Resident Bedrooms: 6 out of 6 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Bedroom 5 had vermin along with medications accessible to the resident, and there were a lot of items in the bedroom.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents.

Medications: 5 out of 5 Medication Administration Records (MARs) were reviewed along with their medications. Resident 4’s medication is not stored in medications original container. Some vitamins did not have physician’s order and/or prescription for residents in care. Prescription nonprescription PRN medication documentation did not include the time medication was provided and residents response to the medication.

Miscellaneous: Documents are posted as mandated. Last disaster drill was conducted on 04/01/2026. The liability insurance is not current. The facility does not have a surety bond. The last Annual Fire Inspection was completed in 2022. The has an Emergency Disaster Plan and Infection Control Plan.

4 staff records were reviewed, 4 out of 4 staff records did not have required documentation.

5 resident records were reviewed, 5 out of 5 resident records did not have required documentation.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC809 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SEDONA GUEST HOME
FACILITY NUMBER: 198204621
VISIT DATE: 05/13/2026
NARRATIVE
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Deficiencies are being cited based on observation, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. Violations ranging from records, facility being in disrepair, vermin in the facility, medication administration, and updating facility sketch.

An exit interview was conducted; Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Caregiver, Nicanor Santos.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC809 (FAS) - (06/04)
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