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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601815
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:01:48 PM

Document Has Been Signed on 04/10/2025 04:01 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:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR/
DIRECTOR:		MATTHEW MAILANGKAYFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 5CENSUS: 4DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Matthew Mailangkay TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Galarza and Myra Cota conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to LVN Cheryl Mayronne. Administrator Matthew Mailangkay arrived later. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) licensed to serve to serve adults over the age of 18 with developmental disabilities who are medically fragile and require 24-hour licensed nursing supports vendored by San Gabriel/Pomona Regional Center. The facility provides transportation services and is equipped with 1 van.

The following were observed/inspected:



Infection Control: The facility does not have a current Infection Control Plan. A technical advisory was issued.

Physical Plant/Environment Safety: The facility is a single-story home that contains five (5) bedrooms fully equipped with mechanical lifts, four (4) bathrooms of which one (1) is equipped with a mechanical lift; a living room, great room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. The facility's last fire inspection was conducted on 11/10/2023 Hendrick Fire Protection.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Electrical smoke carbon monoxide detectors were tested. The facility has sprinklers and charged fire extinguishers. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit. The facility maintains emergency food supply and water. The building contains central air conditioning and heating. A 1st Aid Kit & Manual consisting of thermometer, tweezers, scissors, antiseptic, bandages, and gauze were observed. Emergency Phone numbers, exit plan and programming schedules were posted. The facility has an electric generator and back-up gas generator. The electric generator was tested and is operational, but the gas generator's battery is non-operable. NOTE: Administrator and LVN in charge did not have knowledge of proper generator test procedures.



DEFICIENCIES OBSERVED: 1. Two scissors were unlocked in a kitchen drawer 2. Cleaning supplies, detergents, and toxic substances were observed unlocked/accessible to clients in the bathroom nearest to the kitchen, underneath the kitchen sink, and in the laundry room. 3. Sharp gardening tools were unlocked in the backyard patio area.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALFORD HOME
FACILITY NUMBER: 198601815
VISIT DATE: 04/10/2025
NARRATIVE
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Operational Requirements: Fire clearance is approved for five (5) bedridden residents. Care and supervision to meet the clients needs was observed. Special equipment [mechanical lifts and wheelchairs] are used for all residents. Surety bond was not provided during the visit. A citation was issued.

Staffing: A total of 16 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, certifications, and 1st Aid/CPR training. Staff training is conducted monthly. Administrator certificate expires 8/16/2024.

Client Rights/Information: Personal rights were posted and in client files.

Client Records/Incident Reports: Five (5) client files were reviewed. They contained Individual Health Care Plans (IHCP), IPP, medical assessments, admission agreements, personal rights, medical consent, dietician report, consultant logs, Trust account records, TB clearance, and Medication Administration Records. 30-day supply of client medications were observed locked and given as prescribed.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. All sharps were locked. Two (2) clients have a G-Tube, 1 client has a pureed diet, and 1 client has a chopped diet.

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

Incident Medical and Dental: All residents have updated consultant assessments, Physician Reports, physician orders, 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 4/2/2025.

Emergency Intervention: No manual restraints or seclusion is used in the facility.

Per Title 22, California Code of Regulations, a deficiencies are being cited.



Exit interview conducted with Administrator Matthew Mailangkay. A copy of the report and appeal rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/10/2025 04:01 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/10/2025 at 01:43 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80074(c)
Transportation
Motor vehicles used to transport clients shall be maintained in a safe operating condition.

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 the facility's van is non-operable and in the shop. The facility has 2 loaner vans in the premises. However, documentation of routine maintenance is not on file and documentation provided has expired registration/insurance. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Administrator agreed to submit proof that the van repairs have completed. Submit proof of completed repairs, registration, and insurance.
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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/10/2025 04:01 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/10/2025 at 03:32 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that 2 pairs of scissors in kitchen cabinet, cleaning solutions and detergents were unlocked under the kitchen sink, bathroom sink, and laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator agreed to conduct in-service training and provide POC by tomorrow.
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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/10/2025 04:01 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/10/2025 at 03:32 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(a)
Plan of Operation
(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation.

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 the Plan of Operation was not in the premises, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to submit a written plan of correction that states how the deficiency was corrected.
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

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 the facility handles clients' monies, and no Surety Bond was provided during the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to submit a copy of the current Surety Bond.
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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/10/2025 04:01 PM - It Cannot Be Edited


Created By: Noemi Galarza On 04/10/2025 at 03:32 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: ALFORD HOME
FACILITY NUMBER: 198601815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 that Administrator and LVN did not have knowledge of proper generator test procedures, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to submit a written plan of correction that includes generator test olicy/procedures and staff training.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

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 the facility does not have a current LIC610D (12/21), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to submit a copy of the updated LIC610D form.
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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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