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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601706
Report Date: 05/26/2026
Date Signed: 05/26/2026 03:27:56 PM

Document Has Been Signed on 05/26/2026 03:27 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:BALDWIN GRACIOUS LIVINGFACILITY NUMBER:
198601706
ADMINISTRATOR/
DIRECTOR:		HERMINA PEGOLLOFACILITY TYPE:
740
ADDRESS:14218 ROCKENBACH STTELEPHONE:
(626) 206-5040
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 2DATE:
05/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Arney Tiger Leysa - staffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Arney Tiger Leysa. Administrator Herminia Pegollo arrived shortly after and assisted with the visit. LPA explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 6 non-ambulatory residents of which 1 may be bedridden. Facility approved Hospice waiver for 6.

The facility is a single story structure located in a residential neighborhood. It consists of the following: (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, laundry room, detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked and inaccessible to residents. Smoke / Carbon monoxide detectors were in compliance and operational. There are (3) fire extinguisher located throughout the facility which are fully charged. The common areas (dining room, living room) are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. Medications are centrally stored in a locked cabinet in the kitchen. LPA observed detached garage/ storage room. There is second refrigerator in the garage. Garage/Storage door is locked. The resident bathroom is clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2026
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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Document Has Been Signed on 05/26/2026 03:27 PM - It Cannot Be Edited


Created By: Nune Margaryan On 05/26/2026 at 02:29 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: BALDWIN GRACIOUS LIVING
FACILITY NUMBER: 198601706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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.
LPA observed that that S1 did not have current CPR/First aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
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The administrator will send the copy of CPR certificate to LPA by POC due date and
ensure that at least one person who has CPR certificate will be present at the facility.

Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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.
LPA observed that one residents did not have an annual physicians report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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Administrator will make doctors appionment for residents as proof and then once annual is completed will send LPA updated LIC602
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2026


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BALDWIN GRACIOUS LIVING
FACILITY NUMBER: 198601706
VISIT DATE: 05/26/2026
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 Last emergency/ fire drill was conducted on 05/17/26. LPA reviewed 2 residents and 3 staff files. LPA confirmed staff working have fingerprint clearances. LPA observed that S1 did not have current CPR/First training certificate in their file ( S1 was only staff at the time of visit until Administrator arrived) and one (1) out of two (2) residents did not have an annual physicians report. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Deficiencies have been noted on LIC 809D under Title 22 Regulations.

Exit interview conducted with administrator and a copy of this report and appeal right were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC809 (FAS) - (06/04)
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