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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601300
Report Date: 11/25/2025
Date Signed: 11/25/2025 02:09:02 PM

Document Has Been Signed on 11/25/2025 02:09 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:REDEEMER HOME IIIFACILITY NUMBER:
198601300
ADMINISTRATOR/
DIRECTOR:		JOSEFINA R. BERNALFACILITY TYPE:
735
ADDRESS:1916 VALERIE CTTELEPHONE:
(626) 667-7057
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 6DATE:
11/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:19 AM
MET WITH:Josefina Bernal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Administrator Josefina Bernal and DSP Merly Campos. The facility is licensed as level 4 Adult Residential Facility (ARF) that is licensed for developmentally disabled residents ages 59 and under vendored by San Gabriel Pomona Regional Center.

The following were observed/inspected:



Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment/supplies.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 1 office room, 2 bathrooms, dining room/kitchen, living room, outdoor patio, and an attached garage.The interior and exterior physical plant was inspected. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher and a fire pull alarm. Exit doors are free of any obstruction and there are no pools or large bodies of water. Water temperature measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies and toxic substances are inaccessible to residents.

Operational Requirements: Fire clearance is approved for four (4) ambulatory and two (2) non-ambulatory residents. Care and supervision to meet the clients needs was observed. Special equipment and supplies are used by non-ambulatory residents. The Surety Bond is current with expiration date of 4/23/2026.



Staffing: A total of 6 staff members provide care and supervision to the clients.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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.

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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: REDEEMER HOME III
FACILITY NUMBER: 198601300
VISIT DATE: 11/25/2025
NARRATIVE
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Personnel Records/Staff Training: Administrator certificate expired 2/25/2025. Documentation of recertification processing was reviewed. Criminal background clearance, staff roster, staff training, health and TB clearance, DSP, 1st Aid/CPR, and, CEU's are on file. Staff do not have Direct Support Professional Continuing Education training applicable to residents over the age of 60. Age Exceptions for 3 residents have been in place since January 2024.

Client Rights/Information: Physician orders, and personal rights were reviewed in client files. A resident council is not in place.

Client Records/Incident Reports: Six (6) resident files were reviewed. Admission agreements, Tenant/Landlord Agreements, Physician's Reports, medical/functional assessments, ISP's, TB clearance, IPP reports, personal rights, medical consent, dietician report, consultant logs, and Medication Administration Records were reviewed.

*NOTE: Five out of the six residents are over the age of 60, and only 3 have approved Age Exceptions in place. Residents (R5 & R6) do not have approved age exceptions.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable, 7 day non-perishable food, and emergency supply of food and water. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Three residents requires a modified diet.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were reviewed.

Incident Medical and Dental: Residents have updated consultant assessments, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last emergency drill was conducted on August 1, 2025.

Emergency Intervention: Facility staff do not use emergency intervention techniques.

Per Title 22, citations were issued.



Exit interview was conducted and copy of report/appeal rights was issued to Assistant Administrator Josefina Bernal.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/25/2025 02:09 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/25/2025 at 01:10 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: REDEEMER HOME III
FACILITY NUMBER: 198601300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that residents R2, R3, R5, R6 are over the age of 59 and have annual exams/Physician's Reports over 1 year old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Administrator agred to submit updated Medical Assessments for residents R2, R3, R5, and R6. Licensee shall use LIC 602A because all the aforementioned residents are over the age of 59.
Type B
Section Cited
CCR
80091(a)(4)
Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained. (4) Stage 3 and 4 dermal ulcers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because medical records indicate R3 (over the age of 59) has a chronic stage 4 pressure ulcer on their leg and the resident is not enrolled in hospice, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Administrator shall:
1. Submit proof of current Appraisal Needs and Services Plan
2. Contact the Regional Center to address prohibited health condition, wound care plan, and retention incompatibility
3. Submit written plan of correction that states how the deficiency was corrected
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/25/2025 02:09 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/25/2025 at 01:23 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: REDEEMER HOME III
FACILITY NUMBER: 198601300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(f)
Acceptance and Retention Limitations. The Department may require the licensee to comply with various regulations applicable to RCFE if the Department determines that compliance with any such specific regulations is necessary to protect the health and safety of clients 60 years of age or older….. those pertaining to the training of staff members….. regular observation of clients for changes in physical, mental, emotional, and social functioning and the notification of the client's physician….if any, of documented changes.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because there has been no Direct Support Professional Continuing Education training applicable to residents over the age 59, which have had accepted age exception waivers since Jan. 2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Administrator shall submit proof that all staff have received training in subject matter relevant to individuals 60 years of age or older as agreed upon per approved Age Exception Waivers in place.
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section above in that there are a total of 5 residents over the age of 59. Three residents have Age Exceptions in place. Residents (R5 & R6) are over age 60 and do not have approved age exceptions in place. The census exceeds 50% of allowable residents over the age of 60, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Administrator agreed to: 1. Either relocate residents R5 & R6 OR 2. submit Age Exception requests for R5 & R6 by POC due date. If an extension is needed submit a written request by the 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/25/2025 02:09 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/25/2025 at 01:44 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: REDEEMER HOME III
FACILITY NUMBER: 198601300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(c)
Needs and Services Plan. The written Needs and Services Plan specified in Section 80068.2(a), shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that residents that have approved age exceptions in place do not have Needs and Services Plans and/or LIC 625 Appraisal/Needs and Services Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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Administrator shall submit copies of completed LIC 625 Appraisal/Needs and Services Plan forms for all residents over the age of 60.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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