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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602019
Report Date: 05/15/2025
Date Signed: 05/15/2025 05:18:35 PM

Document Has Been Signed on 05/15/2025 05:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEOPLE'S CARE COVINA HILLSFACILITY NUMBER:
198602019
ADMINISTRATOR/
DIRECTOR:		RAMOS, JOLLIEREY (JOLLIE)FACILITY TYPE:
735
ADDRESS:1412 E COVINA HILLS RDTELEPHONE:
(626) 498-0075
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 4DATE:
05/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Jollie RamosTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 05/15/2025. LPA Ramirez was met by Direct Support Staff Irene Sandoval and explained the purpose of the visit. The facility is licensed serve four (4) developmentally disabled clients of which four (4) may be non-ambulatory. The facility is approved for delayed egress and secured perimeters. All clients in the facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, attached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby.

Dining Room/Living room: Dining room was observed to contain one bench style table with plenty of seating. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and hand washing etiquette in this area.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. All client bedrooms are private.

SEE 809-C

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019
VISIT DATE: 05/15/2025
NARRATIVE
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Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non-slip mats in all bathroom showers. LPA Ramirez observed bathroom#1 to be wheelchair accessible. LPA Ramirez observed two bottles of disinfectant spray under bathroom#2 sink, that was accessible to clients. LPA Ramirez issue one (1) Type A deficiency based on this observation.

Centrally Stored Medications: LPA Ramirez observed centrally stored medications to be inaccessible to clients in care.

Backyard: Well-maintained with plenty of shade and free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 04/01/2025 & 02/08/2025.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed five (5) personnel files. S3’s personnel file did not contain documented proof of criminal record clearance or criminal record exemption. LPA Ramirez will issue Type B deficiency based on this record review. During record review of staff training, LPA Ramirez did not observe documented staff training related to assisting clients 60 years of age or older with personal activities of daily living; the regular observation of clients for changes in physical, mental, emotional, and social functioning. Due to C3, being over the age of 60 years old, LPA Ramirez will issue Type B deficiency based on this record review. Administrator Certificate (7033424753) for Lee Strollo II was observed with an expiration date of 06/05/2026.

Client Files: Four (4) client files were reviewed. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights, and Individual Program Plan was observed. C2 and C3 did not have documented medical assessments in their client flies. LPA Ramirez will issue two (2) separate deficiencies based on this record review. Review of C3’s client file revealed, this licensing agency did not receive a written report regarding C3's injuries and hospitalization in March 2025 & May 2025. LPA Ramirez will issue Type B deficiency based on this record review.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. Six (6) deficiencies were observed and cited during this inspection. A copy of this report, 809-D and appeals rights was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/15/2025 05:18 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/15/2025 at 02:34 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: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

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, LPA Ramirez observed multiple bottles of disinfectant sprays under the sink in bathroom#2, the licensee did not comply with the section cited above in 4 out of 4 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
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Staff immediately removed disinfecatants when LPA Ramirez made observation. No further action is required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/15/2025 05:18 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/15/2025 at 02:34 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: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, documentation of C2's medical assessment was not in their file, the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee will obtain medical assessment and keep documentation in C2's client file. Proof of medical assessment must be sent via fax to LPA Ramirez by 5/22/25.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2025 05:18 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/15/2025 at 02:44 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: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(3)
85068.4 Acceptance and Retention Limitations
(c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: (3) Documentation of a medical assessment, signed by a physician, made within the last year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no documentation of C3's medical assessment made within the last year, was observed in C3's client file, the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee shall obtain documenation of medical assessment made within the last year for C3. Licensee will send proof to LPA Ramirez via fax by 05/22/25.
Type B
Section Cited
CCR
85068.4(f)
85068.4 Acceptance and Retention Limitations
(f) The Department may require the licensee to comply with various regulations applicable to RCFEs 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. Such regulations may include, but not be limited to, those pertaining to the training of staff members who assist clients with personal activities of daily living; the regular observation of clients for changes in physical, mental, emotional, and social functioning; and the notification of the client's physician and responsible person and/or authorized representative, if any, of documented changes. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA Ramirez did not observe documented staff training related to assisting clients 60 years of age or older with personal activities of daily living; the regular observation of clients for changes in physical, mental, emotional, and social functioning the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licnesee will conduct staff training on regulations applicable to RCFEs for assist clients with personal activities of daily living; the regular observation of clients for changes in physical, mental, emotional, and social functioning. Proof of staff training must be submitted via fax to LPA Ramirez by 05/22/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2025 05:18 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/15/2025 at 03:04 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: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80061(b)(E)
80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, this licensing agency did not receive a written report regarding C3's injuries and hospitalization in March 2025 & May 2025, the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee will submit reports for C3 for incidents that occured in March and May of 2025.
Type B
Section Cited
CCR
80019(j)(1)
80019 Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 80066.
(1) Documentation shall be available for inspection by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, S3's personnel file did not contain documented proof of criminal clearance or criminal record exemption,the licensee did not comply with the section cited above in 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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2
3
4
Licensee will obtain copy of criminal record clearance or criminal record exemption for S3 and maintain in personnel file. Proof of clearance or exemption must be submitted to LPA Ramirez via fax by 05/22/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
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