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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602265
Report Date: 02/23/2026
Date Signed: 02/23/2026 12:39:07 PM

Document Has Been Signed on 02/23/2026 12:39 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:SHADY ACRES GUEST HOMEFACILITY NUMBER:
198602265
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, CHRISTINEFACILITY TYPE:
735
ADDRESS:901 N LOS ROBLES AVETELEPHONE:
(626) 356-9168
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 10CENSUS: 6DATE:
02/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Wendy Avalos, DSPTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Wendy Avalos, Direct Support Professional (DSP), and the reason for the visit was explained. Administrator, Chritine Williams, was notified regarding today’s visit telephonically, but was unable to attend due to a prior engagement. Avalos continued to facility the visit.

The facility is licensed to serve (10) ambulatory developmentally disabled clients ages 18 to 59, ambulatory only. The facility is operating within the scope of its license. Currently, there are six (6) clients living in the home. Clients in care receive services through the Frank D. Lanterman Regional Center. The two-story home is in a residential area of Pasadena. The first floor consists of living room, dining room, kitchen, laundry room (which houses the dryer), (2) client bedrooms and (1) full bathroom. The second floor consists of den, (3) client bedrooms and (1) full bathroom. The home also has a front and backyard, and a detached garage/laundry area for the washer.

During today’s visit, the following was observed:

The facility was observed clean inside and out. Walkways, passageways and exits are kept clear of debris and obstructions. Furniture is clean and in good repair on the first floor of the home. Living and dining room have sufficient seating for staff and clients. The kitchen was inspected; however, grease and other mildew were observed on kitchen cabinet doors, and around the floor tile of the corners of the stove. Stove is also soiled with grease on the sides and in the oven. Scissors, igniters, chemicals and cleaning supplies were observed unlocked and accessible to clients in a kitchen cabinet and beneath the kitchen sink. The facility has sufficient 7-day non-perishable supply of food; however, LPA observed that the home does not have sufficient 2-day perishable food supply for clients in care. LPA also observed two bread loafs with mold and two other loafs with expiration dates of 2/16/26 and 2/21/26. Four additional loafs had excessive moisture in the bag. *Continues on LIC 809-C*

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2026
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 8
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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Document Has Been Signed on 02/23/2026 12:39 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/23/2026 at 10:57 AM
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

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, scissors, igniters, chemicals and cleaning supplies were observed unlocked and accessible to clients in a kitchen cabinet and beneath the kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2026
Plan of Correction
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Licensee/Administrator will lock all items in a secure location to prevent clients from having access to them. Staff will send LPA photos of the cleared drawer and cabinet by POC due date.
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff did not ensure that the facility have sufficient 2-day perishable food supply for clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2026
Plan of Correction
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Licensee/Administrator will purchase perishable food and send LPA a copy of the purchase receipt of and a photo of replenished refrigerator by POC due date.
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:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/23/2026 12:39 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/23/2026 at 10:57 AM
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, evacuation chair was not observed by the staircase on second floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2026
Plan of Correction
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Licensee/Administrator will properly install the evacuation chair at the top of the second floor stair case and send photo to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/23/2026 12:39 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/23/2026 at 10:57 AM
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, grease and other mildew were observed on kitchen cabinet doors, and around the floor tile of the corners of the stove. Stove is also soiled with grease on the sides and in the oven, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee/Administrator will send LPA photos of clean areas mentioned in the citation by POC due date.
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, the licensee did not comply with the section cited above in [3] out of [6] client records do not have a current Physician Report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee/Administrator will scan and email LPA copies of (3) clients' current Physician Reports by POC due date.
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:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/23/2026 12:39 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/23/2026 at 10:57 AM
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in due to two bread loafs had mold and two other loafs were observed with expiration dates of 2/16/26 and 2/21/26. Four additional loafs had excessive moisture in the bag, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2026
Plan of Correction
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Loafs of bread were discarded during visit.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to Emergency Disaster Plan (LIC 610-D) not being filled out by staff. All the plan’s elements are missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee/Administrator will email a completed copy of the Emergency Preparedness Plan by POC due date.
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:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265
VISIT DATE: 02/23/2026
NARRATIVE
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Client bedrooms have the required furniture, bedding and sufficient lighting. Latch on window in bedroom #2 (first floor) is broken and windowpanes could not be closed and remain open. Sofa on the second-floor den was observed in disrepair. The lining of the seating and backrest of the sofa are lifted and several tears were observed. Bathrooms were observed and found to be clean and sanitary. However, cabinet door under bathroom #2 sink (upstairs) does not properly close due to having a broken hinge. Water temperature was tested in bathroom #1 and #2 and measured 107.6- and 113.3-degrees F. which is within the compliance range of 105 - 120 degrees F.

Front and backyard are kept clean and garden is maintained. The backyard has a shaded patio area and patio furniture is in good repair. No pools or bodies of water were observed. The laundry area is kept clean, and appliances are in operating condition.

The home has (2) fire extinguishers, charged and operable, and were last inspected on 2/2/26. Carbon monoxide detectors were tested during visit and were operating properly. The facility is equipped with smoke detectors connected directly to the local fire department and the last inspection was conducted on 5/2025. Evacuation chair was not observed by the staircase on second floor. The facility conducts safety drills every month. Last safety drill was conducted on 1/20/2026, with client and staff participation. LPA reviewed Emergency Disaster Plan (LIC 610-D) but was not filled out by staff. All the plan’s elements are missing.

Review of records was conducted for (6) client files. Medical Assessments for Client #1, #4 and #5 were missing from their file. LPA was unable to conduct review of staff records due to staff assisting with visit not having access to them.

An annual continuation visit will have to be conducted at a later date. During today’s visit, Deficiencies noted and citations issued. Exit interview was conducted with Wendy Avalos and a copy of this report, LIC 809-D and Appeal Rights, was provided. Christine Williams was notified about today’s visit outcomes telephonically.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 02/23/2026 12:39 PM - It Cannot Be Edited


Created By: Mayra Cota On 02/23/2026 at 12:21 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: SHADY ACRES GUEST HOME
FACILITY NUMBER: 198602265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to not having staff files available for review during today's visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee/Administrator will email LPA a plan on how to have the staff files accessible for review during their absence.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
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