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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601510
Report Date: 04/30/2026
Date Signed: 04/30/2026 11:49:37 AM

Document Has Been Signed on 04/30/2026 11:49 AM - 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:ELWYN NC - DOREENFACILITY NUMBER:
198601510
ADMINISTRATOR/
DIRECTOR:		HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:5116 DOREEN AVETELEPHONE:
(626) 941-6562
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 5CENSUS: 5DATE:
04/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Alex Tran, RN House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Alex Tran, RN House Manager, and the reason for the visit was explained.

This Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) is licensed to serve (5) adults ages 18 through 59 and (5) may be bedridden. The facility is operating within the scope of its license. Clients in care received services through the Eastern Los Angeles Regional Center. There are currently (5) clients living in the home. The home is in a residential area of Temple City, and it consists of, living room, dining area, kitchen, staff office, (5) client bedrooms, (1) staff and (1) client bathroom, attached garage with laundry area, side patio and backyard.

During today’s visit, LPA observed the following:

The facility is clean inside and out. Walkways, passageways and exits are free of debris and obstructions. Living room and dining area are spacious and accessible for client mobility devices. Kitchen was observed clean and appliances were working properly. The facility has sufficient food/formula for clients. Extra feeding supplies and formula are kept in storage closet. Oxygen tanks are kept properly stored and storage area has oxygen posting visible on the door. Client bedrooms have the required furniture and bedding, and medical-grade beds are appropriately maintained and in good repair. Client bathroom was observed clean and sanitary. Extra towels and personal hygiene products are available for use. Water temperature was tested and measured at 114.7 degrees F. which is within compliance range. The garage is kept clean and extra emergency food and personal hygiene supplies are properly stored and readily available for use. Laundry appliances are operational and in good condition. Side patio has a shaded area and garden is well maintained. Additional seating was observed in the backyard. ***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: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2026
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: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
VISIT DATE: 04/30/2026
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The home has a back-up generator which is inspected every two weeks by staff and inspections are documented accordingly. Generator was last inspected on 4/27/2026. The facility has an updated Emergency and Preparedness Plan and conducts fire/disaster drills every month. Last drill was conducted on 4/6/2026. Three (3) fire extinguishers were observed charged and last inspected on 2/27/2026. Interconnected smoke detectors were tested and found to be working properly. Carbon monoxide detector was also tested and was also observed to be working properly. The home has two client vehicles which have current registration and insurance. Vehicles are regularly inspected by staff and last maintenance on both vehicles was conducted on 4/2/2026.

Medication is kept locked and centrally stored in the kitchen. Medication was observed to be dispensed according to physician orders and documented appropriately. PRN medication is also kept locked in medication cart and inaccessible to clients in care.

Five (5) client and (4) staff flies were reviewed. Files contained relevant documentation.

No deficiencies noted nor citations issued during today’s visit. Exit interview conducted with Alex Tran, RN House Manager, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC809 (FAS) - (06/04)
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