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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600346
Report Date: 12/26/2025
Date Signed: 12/26/2025 02:02:51 PM

Document Has Been Signed on 12/26/2025 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FOSTER AVENUE HOMEFACILITY NUMBER:
198600346
ADMINISTRATOR/
DIRECTOR:		EILEEN CORREOSFACILITY TYPE:
735
ADDRESS:10953 FOSTER AVENUETELEPHONE:
(562) 627-9612
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
12/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Rechele Green, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met with Administrator, Rechele Green and explained the purpose for today’s visit, shortly after Program Director, Eileen Correos arrived to assist with visit. The facility is licensed to serve four (4) Ambulatory Only adults ages 18-59 years. The facility currently has four (4) clients that are serviced through Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.



Physical Plant & Environment Safety: The facility is a single-story home located in a residential area in Norwalk, CA. A tour of the facility includes: four (4) client bedrooms, two (2) full bathrooms (1 bath is in private client room), living room, dining area, kitchen, office area, detached garage with laundry, front yard and backyard. LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. LPA inspected clients’ rooms and each client bedroom has the required furniture such as bed frames, dressers, nightstand, lamps, and chairs. Bedrooms also have sufficient closet space. Extra towels, linens and blankets are in the hallway closet. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. Hygiene products are readily available for clients.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2025
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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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: FOSTER AVENUE HOME
FACILITY NUMBER: 198600346
VISIT DATE: 12/26/2025
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One bathroom contain a working toilet, basin, water faucet, walk-in shower, shower chair, grab bars, and bathmat. The bathroom in the private client room contains a working toilet, basin, water faucet, bathtub/shower, grab bars, and a bathmat. The hot water temperature were measured between 115.5 to 118.7 degrees F. which is within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet. Smoke detectors and carbon monoxide detectors are operable and in compliance. Fireplace is covered and inaccessible to clients. There are two fire extinguishers that are fully charged and last inspected in 09/25/2025. Based on record review, the licensee was issued to serve four (4) ambulatory clients based on the approved fire clearance dated 01/06/2004. However, LPA observed the facility is retaining one client, Client #4 (C4) who is non-ambulatory based on the physician’s report dated 12/19/2024.

Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has a valid Liability Insurance in place. Facility has a valid Surety Bond in place. Facility has an activity area furnished for outdoor use. Last fire drill was conducted on 12/18/2025.

Staffing: A total of nine (9) staff provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and are associated to the facility.

Personnel Records/Staff Training: Staff files are maintained in a secure location. LPA reviewed four (4) staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Administrator’s Certificate expires on 10/22/2026. Administrator’s file also has valid HIV and TB training.

Client Rights/Information: Client personal rights are posted. Facility has internet service accessible to all clients. Working facility phone is available and accessible to clients.

Client Records/Incident Reports: LPA reviewed four (4) client files were reviewed containing Face Sheet, Identification and Emergency Information, Admission Agreements, Physician's Report, TB clearance, Ambulatory Status, Functional Capability Assessment, Individual Program Plan, and Personal Rights. Personal and Incidental (P & I) money were reviewed.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
LIC809 (FAS) - (06/04)
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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: FOSTER AVENUE HOME
FACILITY NUMBER: 198600346
VISIT DATE: 12/26/2025
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Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen. There are no clients that have a modified diet.

Health Related Service: Clients are assisted with self-administration of prescription and non-prescription medications. Three (3) centrally stored client medication records were reviewed. One additional (1) client’s medications were not reviewed since the client is currently away from the facility. Centrally stored medications are kept in a safe and locked place inaccessible to clients in care. Medications are given according to Physician directions. LPA reviewed the First Aid Kit which had all the required items.

Incidental Medical & Dental: All training is documented in the facility personnel files. Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Immediate Civil Penalties is issued on today’s visit in the amount of $500.00 due to facility retaining one (1) non-ambulatory client (C4).

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit will be documented on the LIC809-D. Exit interview was held and a copy of the report and appeal rights were provided to Program Director, Eileen Correos.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/26/2025 02:02 PM - It Cannot Be Edited


Created By: Daniel Konishi On 12/26/2025 at 01:40 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: FOSTER AVENUE HOME
FACILITY NUMBER: 198600346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee was issued to serve four (4) ambulatory clients based on the approved fire clearance dated 01/06/2004. However, LPA observed the facility is retaining one client, Client #4 (C4) who is non-ambulatory based on the physician’s report dated 12/19/2024. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2025
Plan of Correction
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Licensee will get facility back into compliance by getting confirmation for ambulatory status sending Client #4 (C4’s) updated medical assessment or they will relocate Client #4 (C4) or request non-ambulatory fire clearance sending request to licensing and send LPA plan to correct.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2025


LIC809 (FAS) - (06/04)
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