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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600627
Report Date: 11/04/2025
Date Signed: 11/04/2025 12:50:41 PM

Document Has Been Signed on 11/04/2025 12:50 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:DIMENSIONS DAY PROGRAMFACILITY NUMBER:
198600627
ADMINISTRATOR/
DIRECTOR:		GOODUS, DARRYLFACILITY TYPE:
775
ADDRESS:1757 NORTH LAKE AVENUETELEPHONE:
(626) 398-4435
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 75CENSUS: 55DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Montrey Taylor-Vaughn, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Montrey Taylor-Vaughn, Program Coordinator, and the reason for the visit was explained.

The Adult Day Program is licensed to serve 40 ambulatory and 35 non-ambulatory developmentally disabled consumers between the ages of 18 to and 59. The facility is located within the compounds of a church and it consists of: lobby, main hall (activity room), kitchen, (2) gender specific bathrooms, (2) changing rooms with (2) additional bathrooms in each changing room, clock-in room for staff, nurse office, storage closet, (2) consumer locker areas and (2) administrative offices.

LPA toured the facility with Montrey Vaughn, Program Coordinator and observed the following:

The facility was observed clean inside and out. Sufficient staff were observed providing care and supervision for consumers. Furniture throughout the facility is in good repair. Walkways, passageways, exits and ramps were observed to be clear of debris and obstruction. Kitchen was observed clean and refrigerators and small appliances are operable. Refrigerators are available for the storage of staff and consumers’ food. Consumers bring their own lunch; however, cooking activities are conducted as scheduled on the activity calendar. Snacks are also available when incorporated into the schedule. Changing rooms and bathrooms were observed clean and sanitary. Water temperature was tested in each sink and tested between 111.9 – 114.7 degrees F., which is within the required compliance range of 105-120 degrees F. Facility has a medication cart in the nurse’s office for consumers who bring medication from home. Medication cart is kept locked and inaccessible to consumers. During today’s visit, medication for (2) consumers was not at the facility due to consumers not attending the day program for the day. First Aid kit is in the nurse’s office and contains the required tools and manual.

****Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
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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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: DIMENSIONS DAY PROGRAM
FACILITY NUMBER: 198600627
VISIT DATE: 11/04/2025
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 The facility also has several travel First Aid kits which were also observed stocked and readily available for use. Fire drills are conducted monthly, and the last fire drill was conducted on 10/13/25 with staff and consumer participation. Fire extinguishers were observed throughout the facility and are charged and operable. Combination smoke and carbon monoxide detectors in the main hall and the kitchen were tested and observed to be working properly. LPA reviewed (6) consumer and (5) staff files. All files contained all documents to meet compliance.

No deficiencies noted during today’s visit. Exit interview was conducted with Montrey Taylor-Vaughn, Program Coordinator, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
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
LIC809 (FAS) - (06/04)
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