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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602158
Report Date: 08/08/2025
Date Signed: 08/08/2025 04:24:10 PM

Document Has Been Signed on 08/08/2025 04:24 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:JENESIS HOMEFACILITY NUMBER:
198602158
ADMINISTRATOR/
DIRECTOR:		MOCLING, JOANN A.FACILITY TYPE:
735
ADDRESS:9921 SCRIBNER AVETELEPHONE:
(562) 944-1994
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 4CENSUS: 4DATE:
08/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Evelyne De La Cuesta, Direct Support ProviderTIME VISIT/
INSPECTION COMPLETED:
04:30 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) Mayra Cota, conducted an unannounced required annual visit. LPA met with Evelyn Lacuesta, DSP, and explained the reason for the visit. Loida Samonte, Facility Manager, arrived thereafter and assisted with the visit.

The facility is licensed to serve four (4) ambulatory developmentally disabled adults ages 18 to 59 years of age. The facility is operating within the scope of its license. Clients receive services through the Eastern Los Angeles Regional Center. The facility is in a residential area of Whittier.

LPA and Manager, toured the home and inspected the living room/dining area, office, kitchen,
(3) client bedrooms, (2) full client/staff bathrooms, laundry room, front yard, back yard, and attached garage. During today’s visit, LPA observed the following:

Inside the home:
· Facility is clean and furniture was observed to be in good repair. The living room has proper lighting and sufficient seating area.
· Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and mattress pads. There is a closet in the hallway containing extra clean linen and towels. Personal hygiene items for clients are stored in the laundry room.
· The water temperature was tested in both bathrooms and measured at 111.2 degrees F in bathroom #1 and 112.4 degrees F in bathroom #2, which are within the required 105 - 120 degrees F.

***Continues on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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 3
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 3
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: JENESIS HOME
FACILITY NUMBER: 198602158
VISIT DATE: 08/08/2025
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
  • Kitchen appliances were clean and were operating at the time of visit.
  • Sharps/knives were locked in at kitchen drawer and are inaccessible to clients.
  • Cleaning supplies and toxins were also observed locked under kitchen sink.
  • Sufficient supply of 2-day perishable and 7-day non-perishable food was observed, and additional emergency food supply and water was observed, properly stored in a the hallway closet. Food stored in the kitchen and refrigerator is labeled and kept within expiration limits. Additional food supply was observed in the overflow refrigerator in the garage.
  • Smoke detectors are interconnected and were observed throughout the facility. Smoke detectors were tested and all were working properly. Carbon monoxide detector was also tested and observed to be working properly.
  • The facility has (2) fire extinguishers which were last inspected on 11/11/24. Fire extinguishers were observed charged and operable. Last fire/safety drill was conducted on 8/3/25.
  • Two (2) First Aid kit was reviewed and contained all required elements. First Aid manual is kept on hand is readily available for reference.


Outdoor environment:
  • The front and back yard are well maintained and there are no pools or large bodies of water. There is a shaded area in the back yard and is accessible to clients. Garden is well maintained and gardening tools are kept locked in the garage.
  • Passageways, ramp and exits are free of debris and of obstructions.

Medication and record review:
  • Three (3) staff and (4) client files were reviewed and had all required forms in place. Staff and client files are kept locked in a cabinet.
  • Medications for (2) clients were reviewed and were found to be properly dispensed and documented.
  • Client medication is centrally stored in a locked a cabinet by the kitchen.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Loida Samonte, Facility Manager and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3