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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603139
Report Date: 04/18/2025
Date Signed: 04/18/2025 11:31:11 AM

Document Has Been Signed on 04/18/2025 11:31 AM - 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:MAXCELA HOMEFACILITY NUMBER:
198603139
ADMINISTRATOR/
DIRECTOR:		DE GUZMAN, FLORAFACILITY TYPE:
735
ADDRESS:6318 HARDWICK STTELEPHONE:
(562) 920-5635
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 4DATE:
04/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Charlene Borla, Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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 Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced required annual visit. LPAs met with Charlene Borla, Direct Support Staff and explained the reason for the visit and she assisted LPAs with the tour of the facility. Ma. Flora De Guzman, Administrator, arrived shortly after.

The facility is licensed to serve three (3) ambulatory and one (1) non-ambulatory (Hospice waiver for one), developmentally disabled adults ages 18 to 59. The facility is operating within the scope of its license. Clients receive services through the Harbor Regional Center. The facility is in a residential area of Lakewood.

During the visit, LPAs toured the facility's indoor and outdoor environment, reviewed 4 client and 5 staff files, and conducted medication review. The facility is a single-story house which consists of living room/office area, dining room, kitchen, 3 full bathrooms, 4 bedrooms, laundry room, front and backyard, and attached garage.

During today’s visit, LPAs observed the following:



Inside the home:
  • Living room furniture is clean and in good repair. There is sufficient seating for clients in care.
  • The home has a fireplace in the living room which was observed to be covered at the time of visit..
  • Kitchen appliances are clean and working properly.
  • Cleaning supplies and toxins were observed locked under kitchen sink and are inaccessible to clients.
  • Sharps are kept in a kitchen cabinet and were observed locked and inaccessible to clients.
Continues on LIC-809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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 4
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 4
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: MAXCELA HOME
FACILITY NUMBER: 198603139
VISIT DATE: 04/18/2025
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
  • Sufficient supply of 2 day perishable and 7 day non-perishable food was observed. Food was checked and observed to be kept within expiration limits.
  • April 2025 menu is posted in the kitchen.
  • Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space.
  • Client beds have the required linen and mattress pads. There is a closet in the bedroom hallway with extra clean linen, towels, and personal hygiene items for clients.
  • Three full bathrooms were inspected and were observed clean. The water temperature was tested in all the bathrooms and measured within the required 105 - 120 degrees F.

Outdoor environment:
  • The front and backyard are well maintained and there are no pools or large bodies of water.
  • Backyard has a covered patio in good repair and there is enough seating for clients to use.
  • Garage is kept clean and free of clutter.
  • Laundry appliances (washer and dryer) were observed to be working properly. Detergents are kept locked and inaccessible to clients.
  • Passageways and exits are free of obstruction.

Disaster Preparedness and Emergency Intervention:

· Drills are conduced monthly with staff and clients. Last fire/safety drill was conducted on 4/12/25.
· First Aid kits was reviewed and contained required tools and manual.
· Interconnected, combination smoke/carbon monoxide detectors were observed throughout the facility and were tested and observed to be working properly.

***Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MAXCELA HOME
FACILITY NUMBER: 198603139
VISIT DATE: 04/18/2025
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
  • Sufficient PPE supplies observed and stored in a cabinet in the garage.
  • There are two fire extinguishers located in the kitchen and the office space which were observed to be charged. Last fire extinguisher inspection was conducted on both fire extinguishers on 8/23/24.
  • Emergency food supply and water is kept it the kitchen and the medication closet.
  • Emergency Disaster plan and Infection Control Plan reviewed and observed to be up to date.

Medication Review:
  • Medication is centrally stored and locked in medication closet.
  • Client medication was reviewed and observed to be dispensed per physician's orders and documented accordingly on MAR logs.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Ma. Flora De Guzman, Administrator, and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4