<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602031
Report Date: 04/07/2025
Date Signed: 04/07/2025 12:40:51 PM

Document Has Been Signed on 04/07/2025 12:40 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:TOTAL LIFE CARE, INC - EVOLVE SERVICESFACILITY NUMBER:
198602031
ADMINISTRATOR/
DIRECTOR:		MONTESINOS, JESSICAFACILITY TYPE:
775
ADDRESS:545 EREMLAND DRIVETELEPHONE:
(626) 257-3235
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 60CENSUS: 23DATE:
04/07/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nilesh Makwana, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual inspection at the facility. LPA met with Nilesh Makwana, Program Director and explained the purpose of the visit. The facility is licensed to serve age range 18-59. 60 ambulatory of which 10 maybe non-ambulatory developmentally disabled clients.

LPAs utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

1. Infection Control: Facility has an updated infection control plan in place. Facility continues to practice the infection control in the facility. Facility also has sufficient PPE supplies in the facility.

2. Physical Plant and Environmental Safety: The facility is located in residential neighborhood area. The facility includes: office area, reception area, four (4) unisex bathrooms, client kitchen, janitor closet, staff lounge, Art and Music Room, Computer room, Media Room, Evolve Room, Staff kitchen, laundry room, Relaxation/Quiet Room, Education Room, Basic Room, Physical Room, Onsite BCBA office, Conference room, Administrative Office and HR room. LPA inspected the four unisex bathrooms, they are clean and sanitary. The hot water temperature tested between 115.1 degrees F and 119.1 degrees F which is within the Title 22 regulation. All the chemicals and cleaning supplies are stored and locked in the janitor closet. All the sharp knives and utensils are stored and locked in the client's kitchen drawers. The facility has a quiet room for clients to rest if they do not feel good.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: TOTAL LIFE CARE, INC - EVOLVE SERVICES
FACILITY NUMBER: 198602031
VISIT DATE: 04/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
2. Physical Plant and Environmental Safety [Cont.]: The passageway and walkway are free of obstruction. LPA inspected the carbon monoxide detectors and smoke detectors in the facility and they are working well. There are 1 fire extinguisher in the lobby and 3 fire extinguishers in the hallways in which all are fully charged and last inspected on 01/07/2025. Facility has drinking water available for client to use.

3. Operational Requirement: The facility capacity is 60 and which 10 maybe non-ambulatory.

Currently there's about six (6) clients are non-ambulatory which is within the fire clearance.

4. Staffing: Facility has sufficient staffing in the facility and the regional center client and staff ratio are 3:1 and usually they have 2 or 1.9 : 1 and the facility does have the required ratio.

5. Personnel Record-Training: All the staff files are stored in the office area cabinet. LPA reviewed four (4) staff files. All four (4) staff files reviewed are fingerprint cleared and associated with the facility. All four (4) staff files reviewed have personnel record, health screening, TB test result, and Employee Rights. All the staff also have the required 8 hours in service training.

6. Client's Record-Incident Reports: All the client's files are stored in the office area cabinets. LPA reviewed four (4) client files. All four (4) client files included: admission agreement, Individual Program Plan (IPP), face sheet, health screening, TB results, and personal rights.

7. Client's Right-Information: Currently the facility has one client with a helmet and doctor's order in file.

8. Food Service: Clients will bring their own snacks and lunch to the day program and facility staff would assist them to heat up the food. Drinking water is available for client in the facility if needed. All the food are stored properly in the client's kitchen and staff kitchen. All toxins and cleaning supplies are secure, locked, and placed in the janitorial closet away from food supplies.

9. Health Related Services: The medication is centrally stored and locked in a cabinet in a media room and currently one client are taking medication in the facility. LPA checked the MARs and the medications were updated and accurate. All facility staff have the updated first aid certificate and they have at least one staff able to perform CPR.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: TOTAL LIFE CARE, INC - EVOLVE SERVICES
FACILITY NUMBER: 198602031
VISIT DATE: 04/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
10. Incidental Medical Services: Currently there's no client with restricted health conditions.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) on 4/23/24 and the last fire/disaster drill was conducted on 3/28/25. The facility also has two temporary shelter locations.

12. Emergency Intervention: The Facility does not use any restraints or seclusion on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit Interview conducted and a copy of the report was provided to the Nilesh Makwana, Program Director.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4