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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601772
Report Date: 10/14/2025
Date Signed: 10/14/2025 04:42:49 PM

Document Has Been Signed on 10/14/2025 04:42 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:A AND M IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR/
DIRECTOR:		ANA ALARCIOFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Ana Alarcio TIME VISIT/
INSPECTION COMPLETED:
12:48 PM
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Licensing Program Analyst (LPA’s) Gabriela Castro and Christian Gutierrez conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Administrator Ana Alarcio and explained the reason for the visit.

Facility is licensed to serve four (4) developmentally disabled adults, ages 18-59. Four can be non-ambulatory. May retain one (1) hospice client. All clients residing at this facility receive case management services by San Gabriel Pomona Regional Center.

FACILITY TOUR AND OBSERVATIONS:

Personal Rights postings (LIC 613C and Ombudsman) were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is a one-story residential home consisting of four (4) client bedrooms, kitchen, dining room, living room, two (2) bathrooms, an attached garage with storage and laundry, and a backyard patio. All four bedrooms contained the required furniture, including a bed with a clean mattress, linens, dresser, chair, and adequate lighting. Extra clean linens and towels were stored in hallway cabinets, and all furniture was in good condition. Both bathrooms were equipped with working sinks, toilets, and showers, as well as the required grab bars and non-skid mats. Bathrooms had working fixtures, grab bars, and non-skid mats; hot water measured in bathroom (1) 119F and bathroom (2) 120F within 105–120°F. Smoke/carbon monoxide detectors were functional, and a charged fire extinguisher was available mounted in living room. Exits were clear, and no bodies of water were present. Backyard provided shaded seating; garage contained laundry and locked storage for chemicals. During the inspection, the following technical violation was observed: LPA observed an additional mattress in the outside patio that will be moved into the garage.

(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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: A AND M IV HOME CARE
FACILITY NUMBER: 198601772
VISIT DATE: 10/14/2025
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 Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees F and freezer 0 degree F) with sufficient supply of 2-day perishable and 7 days non-perishable food. An additional refrigerator in garage with fresh produce, proteins, and dry goods were stocked. Knives are locked in kitchen drawers and cleaning supplies locked in garage are required to remain inaccessible to clients.

Health-Related Services & Records:
Four (4) client files were reviewed and contained current required documents (Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status, Rights acknowledgments, and IPPs). Medical/dental care was current. Four (4) medications were reviewed; medications are centrally stored in kitchen cabinet, locked, and labeled. MAR logs were current. P&I funds were reviewed.

Disaster Preparedness:
Last fire/earthquake drill was conducted in October 6, 2025, with logs available. LIC 610D Emergency Disaster Plan was posted in [insert location]. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Infection Control Plan was updated.

Personnel Records & Training:
Four (4) staff files were reviewed and included criminal record clearances, CPR/First Aid, DSP training, and TB screenings. Administrator Certificate for Ana Alarcio was valid through August 17, 2026. Staffing ratio met requirements.

Surety Bond & Insurance:
Liability insurance was in compliance with an expiration date of 1/12/26.


An exit interview was conducted with the Administrator Ana Alarcio. During the inspection, the facility was observed to be following Title 22, Division 6 regulations. No deficiencies were cited at this time. A copy of the report will be emailed as LPA's printer is not working.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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