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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602639
Report Date: 05/18/2026
Date Signed: 05/18/2026 04:04:33 PM

Document Has Been Signed on 05/18/2026 04:04 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:D & L RESIDENTIAL CARE HOME 2FACILITY NUMBER:
198602639
ADMINISTRATOR/
DIRECTOR:		RAFAEL DIAZFACILITY TYPE:
740
ADDRESS:1036 S. BARRANCA AVENUETELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 4DATE:
05/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:MMARKJOHN SALONGA, Caregiver/House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:20 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) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the reason for the visit was explained.

The facility is licensed to serve age range 60 and over, six (6) non-ambulatory of which one (1) may be bedridden. Hospice waiver for two (2). The facility is operating within the scope of their license with four (4) non-ambulatory residents, one (1) of which is bedridden. The facility is a single-story home located in a residential area of Glendora. The home consists of a kitchen, living room, dining area, three (3) bathrooms, six (6) resident bedrooms, front and backyards.

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

LPA toured facility interior and exterior and observed passageways and exits to be free of debris and obstructions. Room temperature was kept comfortable. Water temperature was tested in resident bathrooms and measured at 109.5°F in (2) bathrooms, which is within the required 105°F- 120°F. LPA observed grab bars near toilets and inside showers. Shower floor in hall bath was observed to have mold around the shower floor mat and rust around the shower chair. Deficiencies cited. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. Carbon monoxide/Smoke detectors are located in the hallway, were tested and are operable.

continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2026
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 6
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 6
Document Has Been Signed on 05/18/2026 04:04 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 05/18/2026 at 03:11 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: D & L RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in that A/C vents had excessive dust build up which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2026
Plan of Correction
1
2
3
4
Staff agreed to send LPA photos of cleaned vent via email by POC due date.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

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 in that the hall bathroom shower floor had rust from shower chair and mold around floor mat which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2026
Plan of Correction
1
2
3
4
Staff agreed to send LPA photos of clean shower floor via email 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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
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: D & L RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 198602639
VISIT DATE: 05/18/2026
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
LPA observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. All kitchen areas are kept clean and free of litter, rodents, vermin and insects.

Residents’ bedrooms were observed to have required furniture. Two (2) residents had bed rails. LPA observed physician's orders for bed rails in place. Linens were clean and in good repair. Extra, clean linens were observed in a hall closet.

LPA reviewed four (4) resident files. R4 facility file did not have TB clearance available for review. Deficiency cited. The medications are centrally stored in a locked kitchen cabinet. LPA reviewed MAR log. Medications are documented properly and given as prescribed.

LPA reviewed three (3) staff files. Files contained required documents, training, and all staff are cleared and associated to the facility.

The facility has the Emergency Disaster Plan (LIC610) but was not the correct form for the facility type. Technical Violation issued.

LPA reviewed log for quarterly emergency drills. Last drill conducted 01/19/2026.

No pools or large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report along with appeal rights were provided to Caregiver MarkJohn Salonga.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/18/2026 04:04 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 05/18/2026 at 03:46 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: D & L RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 198602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 residents, R4 file did not have TB clearance for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2026
Plan of Correction
1
2
3
4
Staff agreed to provide proof of TB clearance and submit via email to LPA by POC due date.
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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6