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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 08/08/2025
Date Signed: 08/08/2025 12:08:48 PM

Document Has Been Signed on 08/08/2025 12:08 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:HEART TO HOME RESIDENTIAL FACILTYFACILITY NUMBER:
198603201
ADMINISTRATOR/
DIRECTOR:		MINES, JASMINEFACILITY TYPE:
735
ADDRESS:795 E ELIZABETH STTELEPHONE:
(626) 233-0725
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 3DATE:
08/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:51 AM
MET WITH:Edith Williams, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/8/25, stemming from incident report received on 7/1/25. LPA was greeted by Edyssa De Leon, Direct Support Provider, and explained the purpose of the visit. Licensee, Edith Williams arrived shortly after to assist with tour and facilitate record review.

According to Unusual Incident Report received on 7/1/2025, staff self-reported that Client 1 (C1), experienced a sexual assault while out in the community on 6/30/25. C1 returned home the same day and reported the incident to staff. Administrator, transported C1 to the hospital to get checked. Police were contacted by a social worker and police arrived to interview C1 during the hospital visit. Administrator returned to the facility and was present when police dropped-off C1 at the home the next morning after the incident.

LPA conducted interviews with staff and obtained the following information: Licensee and Administrator indicated during interviews, C1 is independent and is accorded autonomy which includes going out into the community unsupervised per Individualized Program Plan (IPP) goals and C1's current capabilities. Staff stated, after the incident, staff have come to an agreement with C1 to have a staff accompany C1 on their trips to the community, to which C1 has agreed. Record review of C1’s IPP held on 3/1/25 indicated, C1 is allowed to go to school independently and to conduct other activities in the community on their own accord.

Telephone interview with Regional Center Director of Program Services (RC) conducted during case management visit by LPA indicated, C1 is independent and can leave the facility alone at anytime as long as staff are informed of C1’s whereabouts. C1 was placed in the facility so that C1 can gain more independence. RC further stated, they have no concerns regarding the care and supervision staff at the facility are providing to C1 because they are following C1’s goals to be part of the community with as much normalcy as possible. RC further indicated, C1 is able to “come and go” as they want to, because the home is not a “locked door” facility. ***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: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 08/08/2025
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LPA interviewed C1 and obtained the following: C1 is in communication with law enforcement and C1 indicated, the case is still ongoing. C1 did not provide more information to LPA about the incident; however, C1 stated, they feel safe in the home and have everything they need. C1 also stated, staff assisted in taking them to the hospital after the incident. C1 further indicated, the regional center has appointed a service provider who will be accompanying C1 to school and to other trips into the community to ensure C1's safety. During interview, C1 appeared to be in a good state of mind. C1 talked to LPA willingly and provided LPA with a copy of the hospital visit on 6/30/25. A tour of the home was conducted, including C1’s room and everything was observed to be clean. Two more clients were observed in the activities room while supervised by a staff member; however, LPA was unable to interview clients due to being non-verbal and of limited comprehension.

No further action is required at this time. LPA Cota may return to gather additional documents. No deficiencies were cited during this visit. Exit interview was conducted with Edyssa De Leon, Direct Support Provider. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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