198602168-5-5-2026-28-AS-NMAN-DTSUHT-20260505153629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602168
Report Date: 05/05/2026
Date Signed: 05/05/2026 03:36:40 PM

Document Has Been Signed on 05/05/2026 03:36 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:	ELLER GEM CORPORATION		FACILITY NUMBER:	198602168
ADMINISTRATOR/ DIRECTOR:	ALICE REYES		FACILITY TYPE:	735
ADDRESS:	18469 ORKNEY ST		TELEPHONE:	(909) 767-1872
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 6		CENSUS: 6	DATE:	05/05/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:55 PM
MET WITH:	Alice Reyes		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Alice Reyes who assisted with the visit. LPA explained the reason for the visit. The physical plant was inspected along with medications, food supply, and resident and staff records. The facility is licensed to serve 6 developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center, which 4 may be non ambulatory. There are currently 6 clients residing at the home.

LPA toured the home and inspected three (3) client bedrooms, one (1) staff room two (2) bathrooms (one related to the staff room), kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. Laundry area was observed in the garage. LPA observed laundry detergent locked in the cabinet and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the living room area which is covered / blocked with the office desk. Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. Extra blankets, linens were observed in the closet located in the hallway. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested at the bathrooms and measured at 132.4 - 134.7 degrees F. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet and inaccessible to clients.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

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: ELLER GEM CORPORATION	FACILITY NUMBER: 198602168
	VISIT DATE: 05/05/2026

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LPA observed the centrally stored medication cabinet in the dining room to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detectors were observed at the facility and working properly. Fire extinguishers observed in the kitchen and in the garage were fully charged and operational. LPA reviewed resident and staff files and observed that all files are updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. Last fire drill conducted on 02/28/26.

Deficiencies have been noted on LIC 809D under Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2026 03:36 PM - It Cannot Be Edited

Created By: Nune Margaryan On 05/05/2026 at 03:21 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: ELLER GEM CORPORATION	FACILITY NUMBER: 198602168
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. The hot water temperature was tested at the bathrooms and measured at 132.4 - 134.7 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2026
	Plan of Correction
1 2 3 4	Hot water adjusted immediately. Citation cleared at the time of visit. The licensee / Administrator will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F as required and will submit a log for the next 24 hours showing the actual reading in both bathrooms.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026

LIC809 (FAS) - (06/04)

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