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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603111
Report Date: 08/04/2026
Date Signed: 08/04/2026 12:27:55 PM

Document Has Been Signed on 08/04/2026 12:27 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:A & A CARE HOMEFACILITY NUMBER:
198603111
ADMINISTRATOR/
DIRECTOR:		CABALLES, CRISTINAFACILITY TYPE:
735
ADDRESS:21207 WILDER AVETELEPHONE:
(562) 233-3125
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Katherine Paez, DSPTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced annual using the CARE inspection tool. LPA met with DSP, Katherine Paez and LPA explained the reason for the visit. Administrator Cristina Caballes arrived shortly and LPA explained the purpose of the visit. Facility is licensed to serve one (1) ambulatory and three (3) non-ambulatory clients between the ages of 18 to 59 years old.

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

Infection Control: Facility maintains an infection control plan. Hand sanitizing and infection prevention were observed at the facility. A responsible person was available at the facility.

Physical Plant & Environmental Safety: Facility is a single-story home located in a residential neighborhood and consists of four (4) client bedrooms, office, living room, a kitchen, two (2) bathrooms, a front yard area, a back patio area and a detached garage. LPA toured the facility and observed that the facility is clean and in good repair indoors and outdoors. Living room, dining room have sufficient seating area. Each client bedroom has sufficient lighting, the required furniture and bedding supplies. Two (2) bathrooms were observed clean and in good repair. Water temperature was tested between 111.0 degrees F to 113.1 degrees F, which is within the required 105-120 degrees F. LPA observed extra linens and towels are in the closet near the hallway. LPA observed no large bodies of water. Carbon Monoxide/Smoke detectors were observed. Laundry area was observed clean and in good repair. Sharps are locked and inaccessible to clients. LPA observed the fireplace being closed and inaccessible to clients. Cleaning supplies and toxins are locked and inaccessible to clients. Kitchen was observed clean, in good repair. [Continue to LIC809-C]

David Sicairos
Daniel Konishi
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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
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: A & A CARE HOME
FACILITY NUMBER: 198603111
VISIT DATE: 08/04/2026
NARRATIVE
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Incidental Medical Services: Per Administrator, none of the clients at this home has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

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

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Cristina Caballes.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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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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: A & A CARE HOME
FACILITY NUMBER: 198603111
VISIT DATE: 08/04/2026
NARRATIVE
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Physical Plant & Environmental Safety [Cont.]: Passageways and exit areas were observed free of obstructions. No large bodies of water were observed. Fire extinguishers were observed and fully charged. The facility has a shaded area in the front yard and backyard for activity purposes.

Operational Requirements: Facility has a fire clearance. The facility has a valid Surety Bond and valid Liability Insurance in place. Last Fire Drill was conducted on 06/01/2026.

Staffing: Sufficient staff were observed during the visit. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records - Training: LPA reviewed five (5) staff that includes Personnel Record, Health Screening, TB Clearance, 1st Aid/CPR/AED training, and Staff Training. Administrator certificate is valid and will expire on 08/20/2027. Administrator has a updated HIV training but was missing in file an updated TB training which should cover tuberculosis, the screening requirements for those in care settings, the pathophysiology of the disease, risk factors, diagnostics, and treatment.

Client Rights - Information: Clients rights and other posters were observed posted throughout the home. A device with internet access is available. Half bed rails were observed in room #1 a physician's order is on file.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. Sufficient food supplies were observed for at least two (2) days of perishables and seven (7) days of non-perishables. Per Administrator, no clients have a modified diet. The food is properly stored in the refrigerator.

Client Records - Incident Reports: LPA reviewed four (4) client files which included Face Sheet, Identification and Emergency Information, Pre-placement Appraisal, Admission Agreement, Functional Capability Assessment, Physician’s Report, Ambulatory Status, TB Clearance, Appraisal Needs and Services Plan, IPP (Individual Program Plan), and Client Rights. LPA reviewed Clients’ P & I.

Health-Related Services: The medications are centrally stored and in their original containers. LPA reviewed three (3) out of (4) clients’ medications as one of the clients, Client #4 (C4) is currently away on vacation and medications are currently with C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Based on record review and staff interview, LPA observed Client #3 (C3’s) medication of Docusate Sodium 100MG capsule was still in the bubble pack. During LPA medication review on the day of the visit, C3 is already at day program and missed the AM dosage of this medication. LPA observed the First Aid Kit that had all required items.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 12:27 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/04/2026 at 12:11 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: A & A CARE HOME
FACILITY NUMBER: 198603111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff interview, LPA observed Client #3 (C3’s) medication of Docusate Sodium 100MG capsule was still in the bubble pack. During LPA medication review on the day of the visit, C3 is already at day program and missed the AM dosage of this medication. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2026
Plan of Correction
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Administrator will submit a written plan by POC due date indicating when they will retrain staff regarding passing of medication. Administrator will submit retrain training materials and sign in sheet to the LPA by 08/18/2026.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 12:27 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/04/2026 at 12:11 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: A & A CARE HOME
FACILITY NUMBER: 198603111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Administrator has a updated HIV training but was missing in file an updated TB training which should cover tuberculosis, the screening requirements for those in care settings, the pathophysiology of the disease, risk factors, diagnostics, and treatment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2026
Plan of Correction
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Administrator will send the copy of the updated TB training certificate to the LPA by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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