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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603089
Report Date: 03/13/2026
Date Signed: 03/13/2026 12:34:55 PM

Document Has Been Signed on 03/13/2026 12:34 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:CARE RESIDENTIAL LLCFACILITY NUMBER:
198603089
ADMINISTRATOR/
DIRECTOR:		WILEY, YAVETTEFACILITY TYPE:
735
ADDRESS:11509 CORBY AVETELEPHONE:
(323) 529-4544
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
03/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Keith ColeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Elena Mallett arrived at the facility to conduct an unannounced Annual visit . LPA met with Staff Toyin and the purpose of the visit was explained. Administrator Keith Cole joined the visit shortly after. The facility is licensed to serve three (3) non- ambulatory clients between the ages of 18 through 59.

The facility is a single-story home, located in a residential area of Norwalk that consists of a living room, dining area, a kitchen, three (3) client bedrooms, (1) bathroom, a detached garage, a front yard and a backyard with a covered shaded area with seating.

LPA completed the visit using Compliance and Regulatory Enforcement Tools (CARE) . The following domains were completed during the visit

Infection Control: Infection Control Plan was reviewed by LPA. Facility follows title 22 regulations and is cleaning and disinfecting regularly. Staff has PPE and practices hand hygiene.

Physical Plant and Environmental Safety: Physical plant is clean and sanitary and the hallways and walkways are free from debris and obstruction. A loose baseboard was observed. A deficiency was cited. See 809-D. Hot water temperature measured within Title 22 regulations in the client bathroom. Facility has combination smoke and carbon monoxide detectors that were tested and operational. A fully charged fire extinguisher was present near the kitchen. Sharps and toxins are locked in cabinets. A bottle of cleaning fluid was observed to be accessible to clients. A deficiency was cited. See 809-D. Client bedrooms contained required light and furnishings. Extra linens and blankets and towels were observed.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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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Document Has Been Signed on 03/13/2026 12:34 PM - It Cannot Be Edited


Created By: Elena Mallett On 03/13/2026 at 11:34 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: CARE RESIDENTIAL LLC
FACILITY NUMBER: 198603089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

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, the licensee did not comply with the section cited above in that a half-filled bottle of Lysol cleaning product was observed to be accessible to clients in an unlocked cabinet under the sink in the clients' bathroom . This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2026
Plan of Correction
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Staff placed cleaning product in locked cabinet during visit. By POC due date, Administrator will fax to LPA a signed staement of understanding of the above regulation that is signed by all facility staff.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2026 12:34 PM - It Cannot Be Edited


Created By: Elena Mallett On 03/13/2026 at 11:34 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: CARE RESIDENTIAL LLC
FACILITY NUMBER: 198603089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

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, the licensee did not comply with the section cited above in that the base board in the hallway was not ahereing to the wall and the plastic drawer in the refrigerator was craked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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By POC due date Administrator will email a picture to LPA showing the repaired baseboard and refrigerator drawer.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 out of 4 out of 5 staff files(S1,S3,S4,S5) reviewed did not contain current First Aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2026
Plan of Correction
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By POC dute date Administrator will send LPA proof of current First Aid training for (S1,S3,S4,S5) via office fax.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/13/2026 12:34 PM - It Cannot Be Edited


Created By: Elena Mallett On 03/13/2026 at 11:34 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: CARE RESIDENTIAL LLC
FACILITY NUMBER: 198603089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

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 2 out of 3 client files(C2 and C3) did not contain a Needs and Services Plan signed by a represative other than the Licensee that was not more than a year old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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By POC due date Administrator will send to LPA via Fax either an IPP or Needs and Services Plan that is not more than a year old that has been signed by a representaive other than the Licensee.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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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: CARE RESIDENTIAL LLC
FACILITY NUMBER: 198603089
VISIT DATE: 03/13/2026
NARRATIVE
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Operational Requirements: Fire clearance approval was observed. Plan of operation was observed. Outdoor activity space with a furnished, shaded area was present. A monthly activity calendar was provided. Clients attend Day Program and on the weekend staff take clients on outings such as community walks, to the mall and to museums.

Personal Records - Training: Locked storage space for staff files was observed. 5 staff files were reviewed for Criminal Background Clearance, First Aid training, initial and ongoing training and health screening. Issues were observed and two deficiencies were cited. See 809-D. Administrator Cole's Administrator Certificate is current.

Client Records - Incident Reports: Locked Storage space for client files was observed. Clients’ files were reviewed for Emergency Face sheet, Physician’s Report with ambulatory status, Needs and Services plan, Admission Agreement and Personal Rights. Files for all three clients in care were reviewed and a deficiency was cited. See 809-D

Client Rights - Information: Required postings were observed. Administrator will obtain Ombudsman poster.

Food Service: Kitchen had functional appliances and was equipped to store and prepare food. A drawer in the refrigerator was observed to be cracked/broken. A deficiency was cited. See 809-D .2 day perishable and 7 day non perishable food supply was observed. Food was kept separate from cleaners, toxins and poisons. A sample menu was provided.

Health Related Services: First Aid Kit and manual was observed. Facility utilizes a Medical Record Log. All three clients medicine logs were reviewed with no issues.

Disaster Preparedness: Facility has emergency disaster plan in place. Administrator will send updated Disaster Plan form to Licensing containing more detail. Facility conducts quarterly disaster drills. The last drill was conducted on 02/09/26.

Facility handles clients' P&I money. Ledger was reviewed with no issues. Facility maintains a Surety Bond.

An exit interview was conducted with Administrator Keith Cole. Deficiencies were cited today Per 22 Regulations. A copy of this licensing report and Appeal Rights were provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
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