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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603006
Report Date: 03/10/2026
Date Signed: 03/10/2026 03:06:42 PM

Document Has Been Signed on 03/10/2026 03:06 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:GOODEN RESIDENTIAL WELLNESS CENTER #4, THEFACILITY NUMBER:
198603006
ADMINISTRATOR/
DIRECTOR:		MITCHELL, CORY BFACILITY TYPE:
772
ADDRESS:539 N LOS ROBLESTELEPHONE:
(626) 755-3021
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 6CENSUS: 3DATE:
03/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Cory MitchellTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Administrator Cory Mitchell and explained the reason for the visit.

The facility is licensed as a Social Rehabilitation Facility. It has a Social Rehabilitation Program Certificate - Transitional Residential Treatment Program, which is approved by Department of Health Care Services with effective date from 04/29/26 to 04/29/27. Facility does not vendorize with the Regional Center. Clients are private pay with their insurance. Facility does not currently serve any clients with restricted health conditions.

The facility is licensed to serve six (6) adult ambulatory clients. The facility is a two-story home located in a residential area and consists of three (3) client bedrooms, three (3) bathrooms, a staff bathroom, a kitchen, a living room, an activity room, a laundry room in the basement, a front porch, a detached garage, and a back yard.

Today’s inspection consisted of applying CARE tool, conducting physical plant, reviewing staff/client records, checking client’s food supply/medication, and interviewing staff/clients.

Infection Control: Facility maintains an infection control plan. A responsible person was available at the facility.

Physical Plant & Environmental Safety: The facility was in good repair. Living room and activity room were observed with sufficient furniture. Client’s bedrooms and bathrooms were in good repair and in compliance. (- Continued on LIC 809C-)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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: GOODEN RESIDENTIAL WELLNESS CENTER #4, THE
FACILITY NUMBER: 198603006
VISIT DATE: 03/10/2026
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Kitchen was observed clean. Cleaning supplies and sharps were locked in storage cabinets. Fireplaces were not in use. Passageway, exits and stairways were free of obstruction. Smoke detectors were tested and in working condition. Laundry area and storage area were located in the basement. Outdoor had shaded seating area for client use. Water temperature was tested and the temperatures were between 108.5 - 109.9 degrees F., which is in compliance with regulations. No large bodies of water were observed. Auditory devices were operable.

Operational Requirements: Client's records of personal belongings was reviewed. Supervision was available at all times. No clients were required accommodations in place.

Staffing and Personnel Records - Training: Two staff were observed during the visit. Staff records were reviewed and in compliance. Administrator certificate for Cory Mitchell was current, with expiration date on 7/29/26.

Client Records - Incident Reports: All client records were available for review and in compliance.

Food Service: Facility has a Meal preparation waiver, and meals are delivered by their main kitchen three times a day. Facility maintains snacks and preferences on site. No clients with modified diets.

Health-Related Services and Incidental Medical Services: Medication was centrally stored. All clients needed assistance to administer their medication. Medication was logged to track PRN medication intake.

Disaster Preparedness: Emergency Disaster Plan LIC610D (12/21) was observed and last reviewed on 2/5/25. Last emergency drill was conducted on 3/31/25 and are conducted quarterly. Evacuation chairs were observed. Emergency food supplies were observed in the basement.

Exit interview was conducted with administrator Cory Mitchell and this report LI 809s was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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