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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600567
Report Date: 07/29/2025
Date Signed: 07/29/2025 12:00:29 PM

Document Has Been Signed on 07/29/2025 12:00 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:SANTOS HOME-LAKEWOODFACILITY NUMBER:
198600567
ADMINISTRATOR/
DIRECTOR:		JAY S. SAMILINFACILITY TYPE:
735
ADDRESS:5719 OLIVA AVE.TELEPHONE:
(562) 531-7118
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: 4DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Amelita De Gala, DSPTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual visit at the facility using the CARE Tool. LPA met with the Direct Support Professional (DSP), Amelita De Gala and explained the purpose of the visit. Assistant Administrator, Rhona Amado arrived shortly after to assist with the visit and the LPA explained the purpose of the visit. The facility is licensed to serve four (4) ambulatory only developmentally disabled clients ages 18-59 years old. Facility is operating within the scope of its license.

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



1. Infection Control: The facility has an Infection Control Plan in place and the facility continue to practice infection control with hand washing and disinfecting the facility. The facility has sufficient PPE supplies.

2. Physical Plant and Environmental Safety: A tour of the single-story residential home included the living room, dining area, kitchen, two (2) client bedrooms, one (1) staff room, two (2) bathrooms, an attached garage, front yard, and backyard. Each client's bedroom has two beds, two drawers, a nightstand, the required furniture and bedding and sufficient lighting and close space. The clients’ bathrooms are in good working condition. However, LPA and Staff #1 (S1) observed small bugs crawling in the bathroom cabinet and wall. Extra bed linens, sheets, pillowcases, and towels are located in the hallway cabinet. The hot water temperature in both bathrooms were tested between 105.0- and 105.1-degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. All the sharps are locked in the medication cabinet. All the chemical and cleaning supplies are stored and locked underneath the kitchen sink.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 5
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: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567
VISIT DATE: 07/29/2025
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2. Physical Plant and Environmental Safety {Cont.]: There's a telephone service on the premises. No bodies of water were observed in the facility. LPA inspected the carbon monoxide detectors and it's working well. The passageway, walkway and patio are free of obstruction. A fire extinguisher was observed in the kitchen and is fully charged. Shaded areas in the backyard are provided.

3. Operational Requirement: The facility is approved for four (4) ambulatory clients and currently all clients are ambulatory, which is within the fire clearance requirement. The clients can participate the community events if there's an opportunity. There are tables and chairs in the covered patio area for clients to utilize the outdoor activity. The last fire drill was conducted on 7/24/2025.

4. Staffing: The facility has sufficient staffing. The night staff has the required emergency planned procedure training.

5. Personnel Records-Training: All staff files are stored and locked in the staff office. All the facility staff are over 18 years old, fingerprint cleared and associated with the facility. LPA reviewed four (4) staff files which include: personnel record, health screening, TB test result, required training hours and updated first aid certificate. The administrator’s certificate is valid until 06/02/2026. However, based on record review, the Administrator does not have the updated HIV and TB training certificate.

6. Client's right information: Currently no clients require any postural support. The facility has served internet services with at least one internet access device, so clients can communicate with their family or day program or physician.

7. Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with modified diets residing at this facility. Plates, cups and utensils are kept clean and stored properly.

8. Client's Records-Incident Reports: All the client's files are stored and locked in the kitchen cabinet. LPA reviewed four (4) client's files which include: face sheet, physician report with TB test result and ambulatory status, admission agreement, Individual program Plan (IPP), Personal Rights, and Appraisal/Needs and Services Plan.

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

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567
VISIT DATE: 07/29/2025
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9. Health Related Services: The facility will assist clients with their medical and dental appointments with transportation too. LPA reviewed three (3) clients’ medications and all medications are centrally stored in the kitchen cabinet and they all seem updated and accurate. LPA reviewed the first aid kits which included all required items.

10. Incidental Medical Services: No client in the facility has any restricted health condition or prohibited health condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan. The facility has at least two shelter location in place. The facility conducted fire/disaster drill on 07/24/2025.

12. Emergency Intervention. The facility does not use any restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Assistant Administrator, Rhona Amado.

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

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/29/2025 12:00 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/29/2025 at 11:54 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: SANTOS HOME-LAKEWOOD
FACILITY NUMBER: 198600567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that the Administrator did not have an updated HIV and TB training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
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Administrator will send the updated HIV and TB training to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80087(a)(1)
(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA and S1 (Staff #1) observed small live bugs crawling in the bathroom faucet, wall, and cabinet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2025
Plan of Correction
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Administrator will write up a plan on how to keep the facility free from ants and other insects and send the plan to the LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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