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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600155
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:02:06 PM

Document Has Been Signed on 01/28/2025 02:02 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:SOUTHERN CALIFORNIA ASSISTED LIVINGFACILITY NUMBER:
198600155
ADMINISTRATOR/
DIRECTOR:		RYAN MAGNOFACILITY TYPE:
735
ADDRESS:1510 EDANRUTH AVENUETELEPHONE:
(626) 813-2552
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 6CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Ivan SisonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nune Margaryan and Nicol Wesley conducted an unannounced annual visit using the Care Tool. LPAs met with staff Sison Ivan. LPAs explained the reason for the visit. House Manager Leilani Telebrico arrived shortly after and assisted with the visit. The facility is approved for six (6) ambulatory developmentally disabled adults, ages 18-59. There are currently six (6) clients residing in this facility and receive services from San Gabriel/Pomona Regional Center.

This is a single-story home located in a residential neighborhood and consists of the following: 4 clients bedrooms, living room, dining area, stock / supply room, office, 1 clients bathroom, 1 staff bathroom (inside of office), kitchen and laundry area. The facility has an open front yard and enclosed backyard with an attached patio cover. There are no pools or large bodies of water. When LPAs enter the facility they observed a glass cleaner on the entrance. Also, LPAs observed that unused exercise equipment, suitcase, box of rocks, area rag at the exit door in the back of the facility. also there was unused/empty rabbit cage in the back yard and around of cage were a few rocks and bricks, and the plastic crate with exercise waits. Client bedrooms and bathroom were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathroom is clean and have the required hygiene items. The hot water temperature was tested and was measured at 110.4 degrees F. LPAs observed that the towel rack was broken in the bathroom. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. LPAs observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the laundry area. 2 fire extinguishers observed in the laundry and in the living room fully charged. Carbon monoxide/smoke detectors in the hallway / living room and in the client rooms are operational. At the time of visit the temperature at the common area (dining , living) was 58.4 degrees F.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155
VISIT DATE: 01/28/2025
NARRATIVE
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The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the living room. LPAs reviewed clients and staff files. LPAs confirmed staff working have fingerprint clearances. LPAs reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiencies are documented on 809D.

Exit interview conducted with House Manager Leilani Telebrico and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/28/2025 02:02 PM - It Cannot Be Edited


Created By: Nune Margaryan On 01/28/2025 at 12:57 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: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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. The towel rack was broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Licensee / administrator will buy new towel rack and replace the broken one and will send a picture of proof to LPA via email before POC due date.

Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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. LPAs observed that unused exercise equipment, suitcase, box of rocks, area rag at the exit door in the back of the facility. also there was unused/empty rabbit cage in the back yard and around of cage were a few rocks and bricks, and the plastic crate with exercise waits,
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee / administrator agree to by the shed for unused items left in the back yard and will send the picture of proof to LPA before POC 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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/28/2025 02:02 PM - It Cannot Be Edited


Created By: Nune Margaryan On 01/28/2025 at 12:57 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: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. When LPAs enter the facility they observed a glass cleaner on the entrance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Glass cleaner removed and locked at the time of visit.
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

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. At the time of visit the temperature at the common area / dining , living was 58.4 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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License / administrator will purchase portable electric heater that will heat the dining and living areas and will provide comfortable enviroment to clients in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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