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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602178
Report Date: 08/07/2025
Date Signed: 08/08/2025 05:58:59 PM

Document Has Been Signed on 08/08/2025 05:58 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:A & E RESIDENTIAL CAREFACILITY NUMBER:
198602178
ADMINISTRATOR/
DIRECTOR:		BITUIN, EMELITAFACILITY TYPE:
740
ADDRESS:1286 W BASELINE ROADTELEPHONE:
(909) 399-5189
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 0DATE:
08/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emelita BituinTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Required Annual Visit. LPA met with Licensee/Administrator Emelita Bituin, and explained the purpose of the visit. The Residential Care Facility for the Elderly is licensed to serve six (6) Non-Ambulatory residents ages 60 and above. Facility has an approved Hospice Waiver to retain/accept six (6) residents of which one (1) may be Bedridden. Currently, there are zero (0) residents in placement, zero (0) Hospice, zero (0) Bedridden (0) Exceptions, and zero (0) receiving Home Health Care. LPA did not observe residents at the time of this visit. LPA Madyun requested copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020) however, due to the facility currently not having any residents or staff, no copies were provided.

Physical Plant/Environment Safety: A tour of the single-story facility began at approximately 9:30am that included residents’ rooms: one (1) private staff bedroom, three (3) semi-private bedrooms, two (2) bathrooms, living room, dining area, kitchen, and indoor/outdoor activity areas. All residents bedrooms have the required furniture for privacy, comfort, and safety; bedroom #2 was missing a chair. LPA observed the carbon monoxide detectors, fire sprinklers, and inter-connected smoke detectors with back-up battery throughout the hallway and rooms. LPA observed required auditory devices on exits. Fire extinguisher was fully charged. First-aid kit was fully stocked. LPA did not observe the Emergency Disaster Plan.



Front Yard: Was clean and well maintained without any hazards.

Continued LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A & E RESIDENTIAL CARE
FACILITY NUMBER: 198602178
VISIT DATE: 08/07/2025
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Kitchen: LPA observed a sufficient number of perishables for two (2) days, and a seven (7) day supply of non-perishables. LPA observed knives and sharps located in the kitchen cabinets to be inaccessible to zero (0) out of zero (0) residents in care. LPA Madyun observed several bottles of cleaning solutions and disinfectants located in the bottom kitchen cabinet to be locked away secure and inaccessible to zero (0) out of zero (0) residents in care. Kitchen appliances were observed to be clean and in working order. LPA observed a fully charged fire extinguisher in the corner of the kitchen area.

Dining Room/Living room: Dining room was observed to be clean and contained one table with ample seating. The living room was observed with ample seating and lighting.

Linen Closet: Contained sufficient linens, towels, and hygiene products.

Bathrooms: Bathrooms are clean and operational with grab bars, and non-skid mats were hanging, but not in place. Water temperature in resident bathroom #1 was measured at 132.5 degrees Fahrenheit, and master bathroom #2 was measured at 128.4-129.6 degrees Fahrenheit, which is not within the required 105-120 degrees Fahrenheit requirement. Both bathrooms were observed to be clean and in good condition.

Centrally Stored Medications: Not Applicable due to no residents in the facility at this time.

Backyard: LPA observed multiple shaded seating areas. No large bodies of water were observed.

Emergency Drills: Not Applicable due to no residents in the facility at this time.

Staff Personnel Files: Not Applicable due to no residents in the facility at this time.

Resident Files: Not Applicable due to no residents in the facility at this time. Required postings were not displayed.

Liability Insurance & Infection Control Plan: Licensee currently does not hold Liability Insurance. Annual fee of $495.00 was overdue as of 08/05/2025. Infection Control Plan was received by the Department on 08/07/2025.

LPA observed the facility is being utilized as a private home, with family members residing in the home.

Exit interview was conducted with Licensee/Administrator Bituin, in which Licensee stated they no longer wish to be licensed, and would like to forfeit their license due to financial reasons. A copy of this report and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
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)
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