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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 10/27/2025
Date Signed: 10/27/2025 03:02:15 PM

Document Has Been Signed on 10/27/2025 03:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MY LADIES GUEST HOUSEFACILITY NUMBER:
198602936
ADMINISTRATOR/
DIRECTOR:		TILLMAN, GREGFACILITY TYPE:
740
ADDRESS:128 N FOURTH STREETTELEPHONE:
(626) 863-6349
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 15CENSUS: 10DATE:
10/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:44 AM
MET WITH:Rosealie Ngo, Licensee and Greg Tillman, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:11 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA Lopez met with Licensee Rosalie Ngo and explained the reason for the visit.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.



Operational Requirements:

A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for two (2) resident is approved.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:

Facility is in good repair indoor and outdoor. Kitchen is clean, refrigerator and freezer are in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and medication are kept in the kitchen. Residents do not have access to the kitchen but are able to request any food item at any time. Each resident's room (8) was observed with sufficient lighting, required furniture, and bedding supplies.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MY LADIES GUEST HOUSE
FACILITY NUMBER: 198602936
VISIT DATE: 10/27/2025
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(Continued from 809C)

Room #3 is being used by staff. Each bathroom (7) was observed in working condition, grab bars and skid mats were observed, and water temperature was tested between 105.9 -117.7 degrees F., which is within the required 105-120 degrees F. Cleaning supplies are kept in a lock closet in the hallway. Additional bedding supplies were observed. First aid is available with all the required items. Living room, dining room, and family room are clean and have sufficient seating space. Motion sound detector device was observed in the front door, door going to the laundry, and gate in the side patio. Cameras were observed in the common areas. Carbon Monoxide/Smoke detectors were observed and in working condition. One room did not have a smoke detector and staff promptly placed one in room. Fire extinguishers were last checked on 08/01/2024 Last fire drill was on 09/01/2025 and disaster drill was on 09/01/2025

Food Service:

Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Staffing:

There appears to be always sufficient staffing in the facility. With night staff that are trained and able to assist in care and supervision of the residents in case of an emergency.

Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Health screening for one staff member is missing one page. Administrator Greg Tillman certificate expires on 10/09/2026.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman posted at facility

A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.

Currently facility has one (2) hospice residents and has waiver for two (2) and has requested additional 3.

(continued on (809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MY LADIES GUEST HOUSE
FACILITY NUMBER: 198602936
VISIT DATE: 10/27/2025
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(continued fro 809C)

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Three (3) of (10) resident’s PRN did not have labels on bottles. Medical and dental transportation is provided by family and transportation services.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers but only has 1 relocation site. LIC610 needs to be updated with second relocation site.

Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies.

No deficiencies were cited today. Technical advisories provided.

Exit interview was conducted with staff. A copy of the report, technical advisories and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
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