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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600628
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:54:06 PM

Document Has Been Signed on 01/30/2025 03:54 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:CIENEGA RESIDENTIAL CAREFACILITY NUMBER:
198600628
ADMINISTRATOR/
DIRECTOR:		MARGIE CANLOBOFACILITY TYPE:
735
ADDRESS:20829 EAST CIENEGA AVENUETELEPHONE:
(626) 257-3616
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Jenefer Tayag DSPTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Jenefer Tayag at approximately 1:30 PM and explained reason for visit. Administrator Margie Canlobo was notified by telephone.

The facility is licensed to serve 6 non-ambulatory developmentally disabled clients aged 18 to 59. Currently, there are five (5) clients in placement. Three clients are over 60 years of age. All clients residing at this facility receive case management services provided by San Gabriel/Pomona Regional Center. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, family room, kitchen, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and attached garage.


LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout bedroom #1 and bedroom #3 needed batteries. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in kitchen and has not been inspected since 2023 deficiency cited. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does have a swimming pool and is covered and locked with a gate. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 01/30/2025 03:54 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/30/2025 at 03:12 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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 in two (2) out of four (4) bedrooms fire alarms need battries to be replaced, fire extinguisher needs to be inspected and auditory devices on doors need to be working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator will replace all battires in devices and schedule an inspection for fire extinguisher and send LPA by POC due date.
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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/30/2025 03:54 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 01/30/2025 at 03:12 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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
85088(f)(1)(B)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements: (B) Transmission of a visual and/or auditory signal to a central location, or production of an auditory signal at the client's living unit which is loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628
VISIT DATE: 01/30/2025
NARRATIVE
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in December of 2024. Infectious control plan was reviewed. One (1) staff and (2) client was interviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies noted. Exit interview and a copy of this report, 809D and appeal rights was provided to Staff Jenifer Tayay.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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