198204800-11-4-2025-11-AS-BALN-DN52E9-20251104161933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204800
Report Date: 11/04/2025
Date Signed: 11/04/2025 04:19:40 PM

Document Has Been Signed on 11/04/2025 04:19 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	MY MOTHER'S PLACE		FACILITY NUMBER:	198204800
ADMINISTRATOR/ DIRECTOR:	HILDA LOZANO		FACILITY TYPE:	740
ADDRESS:	11827 ROSE AVENUE		TELEPHONE:	(310) 707-7768
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY: 6		CENSUS: 5	DATE:	11/04/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Gabriela Torreblaca Support Staff		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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At 9:20AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a continuation annual inspection. LPA Allen was greeted by Administrator Hilda Lozano upon arrival. LPA introduced herself and explained the purpose of the visit.

During the prior visit LPA observed bedrooms 1,2,3,4 and 5 to have cameras installed however it has been determined that the device is a Vtec Baby monitor not cameras.

On 10/22/2025 there was a typo LPA reviewed files for Resident 1-5 (R1-R5) and observed that all files were missing required documentation needs and service plans or current physicians’ report for R3, R4 and R5. The administrator has agreed to get current needs and service plans or current physicians’ report for R3, R4 and R5.

A citation will be issued for not having complete files

S1,S2 and S4 needs to be fingerprinted and associated to work at the facility Hilda Lozano have been informed and agreed that any staff who are not cleared should not be working until clearance is issued.

A citation will be issued for not having staff cleared/associated.

Staff members S1-S5 (S1-S5) did not have complete files to review during the visit and was cited based on regulation 87412(a)

LPA advised Hilda Lozano Administrator was informed that due to insufficient time LPA would return to complete the annual inspection on another date and citations will be issued for not following Title 22 Regulations on the continuation inspection visit.

An exit interview was conducted, and this report was discussed and provided to Gabriela Torreblaca Support Staff at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

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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Document Has Been Signed on 11/04/2025 04:19 PM - It Cannot Be Edited

Created By: Bernadette Allen On 11/04/2025 at 03:24 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: MY MOTHER'S PLACE	FACILITY NUMBER: 198204800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

(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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited aboveduring the review of records S1-S5 did not have a complete file for review which consisted of annual 10 hours annually list provided at the time of visit, first aid/cpr certifications and health screenings which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2025
	Plan of Correction
1 2 3 4	The administrator has agreed to have each staff members file completed with all required documents by the POC date of 11/10/2025. Which will inclued annual 10 hours annually ltraining, first aid/cpr certifications and health screenings.

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.

	Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:

	Bernadette Allen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

LIC809 (FAS) - (06/04)

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