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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602536
Report Date: 07/28/2026
Date Signed: 07/28/2026 12:18:40 PM

Document Has Been Signed on 07/28/2026 12:18 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:SVS PASADENAFACILITY NUMBER:
198602536
ADMINISTRATOR/
DIRECTOR:		NANONG-YRIGOYEN, KIMBERLYFACILITY TYPE:
775
ADDRESS:180 N VINEDO AVETELEPHONE:
(626) 773-7254
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 75CENSUS: 25DATE:
07/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:44 AM
MET WITH:Kevin Aguilar, Case ManagerTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with the Case Manager, Kevin Aguilar and LPA explained the purpose of the visit. Program Director, Kimberly Yrigoyen arrived shortly after and LPA explained the purpose for the visit. Facility is licensed to serve 75 adults, of which 15 may be non-ambulatory, ages 18 and over.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies. The facility has an Infection Control Plan in place.

Physical Plant & Environment Safety: This is a single- story facility located in Pasadena, Ca. A tour of the facility includes: lobby/locker/waiting room area, a conference room, seven (7) offices (some of which are used as storage), an isolation/quiet room, computer room, media room, kitchen, gym, salon (styling room), art room, staff break room, library, four (4) restrooms and two (2) changing rooms. Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility. The fire extinguishers were observed which are fully charged and last inspected on 11/25/2025. No bodies of water were observed at the facility. The hot water temperature was tested throughout the facility restrooms and measured between 110.6 degrees F to 113.5 degrees F which are within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. There are two (2) water fountains that are readily available for the clients. The facility appears to be clean safe and sanitary.

David Sicairos
Daniel Konishi
DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2026
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 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: SVS PASADENA
FACILITY NUMBER: 198602536
VISIT DATE: 07/28/2026
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Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements.

Staffing: There appears to be sufficient staffing in the facility. Per Program Director, there are at least twenty (20) staff members on-duty any time there are clients in the facility. Per Program Director, the staff to client ratio is one (1) Community Inclusion Facilitator (CIF) to three (3) clients.

Personnel Records-Training: LPA reviewed five (5) staff files that include Job Application, criminal record clearance, Employee Rights, valid First Aid/CPR/AED training, valid CPI training, and sufficient on-going training. The Program Director has an Administrator’s Certificate that is valid and expires on 05/14/2027.

Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files. LPA reviewed five (5) client records that included the Face Sheet, Admission Agreement, Physician's Report, and Appraisal Needs & Services Plan, Individual Program Plan (IPP), and Client Rights.

Client Rights-Information: Client Rights Poster and Reporting Poster are posted within the facility. Per Program Director, there are no clients that use postural supports.

Food Service: Pesticides and other similar toxic substances are not stored near food/kitchen areas.

Health Related Services: Per Program Director, there are currently no clients that take medications at the facility. LPA reviewed five (5) staff files that include a valid First Aid/CPR training. Facility also has all required items in the First Aid Kit.

Incidental Medical & Dental: Staff have proper training and training is documented within the personnel files. Per Program Director, there are no clients who have a restricted health condition.



Disaster Preparedness: The facility has an updated Emergency Disaster Plan with contact numbers and relocation sites and maintain record of the required emergency drills with last drill conducted on 1/20/2026.

Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was conducted and a copy of report was provided to the Program Director, Kimberly Yrigoyen.

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

DATE: 07/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026
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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