198603201-9-4-2025-28-AS-MCOA-DL7VFW-20250904162438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 09/04/2025
Date Signed: 09/04/2025 04:26:48 PM

Document Has Been Signed on 09/04/2025 04:26 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 FACILTY		FACILITY NUMBER:	198603201
ADMINISTRATOR/ DIRECTOR:	MINES, JASMINE		FACILITY TYPE:	735
ADDRESS:	795 E ELIZABETH ST		TELEPHONE:	(626) 233-0725
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 4	DATE:	09/04/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:38 PM
MET WITH:	Jennifer Torres, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 9/4/25, stemming from incident reports received by the department regarding Client 1 (C1). Special Incident Reports (SIRs) indicate date of ocurrance on 8/27/25 and 8/30/25. LPA was greeted by Kurt Rumbaua, Direct Support Provider, and the reason for the visit was explained. Jennifer Torres, Administrator, arrived shortly after to assist with the visit.

According to the first SIR, C1 eloped from the day program C1 regularly attends on 8/27/25 during a visit to the local park. According to Staff 1 - Staff 3 (S1-S3), facility staff were informed about the incident by day program staff. The day program called the police to report the elopement and police visited the home to obtain more information about C1. On 8/28/25, facility staff received a call from Burbank Police indicating, C1 had been found and was safe. Police informed staff, C1 did not have any obvious injuries, but did show signs of moderate sun exposure on his face. Facility staff, brought C1 back home and assisted with providing them with hydration and resumed with C1's medication. Interviews with S1-S3, further indicated, C1 stated, they walked away from the day program group because C1 was sad because C1's sister had not replied to C1's texts or answered their calls. S1 and S2 indicated, Regional Center was informed of the incident and C1 resumed their normal activities in the home and returned to participate in the day program the next day.

According to the second SIR, C1 reported alleged abuse from a facility staff member to the police. Interviews with S1-S3 indicated, police visited the facility on 8/30/25 to obtain the contact information for staff named on the report as the alleged abuser. Police did not provide details regarding the alleged incident; however, police did provide a report number to staff. S1-S2 stated, they talked to the staff member named on the report as the and the staff member stated, they have not done anything inappropriate nor abusive toward C1 or any other client and will cooperate with the police when contacted. ****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: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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: 09/04/2025

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S1-S3 indicated, staff named on the report stated, in a past incident which occurred on 4/19/25, C1 attempted to elope from the home in which staff member intervened by running after C1 to prevent C1 from leaving and from crossing a dangerous street. According to information S1-S3 received from staff member, based on emergency situation, staff member had to use moderate strength to prevent C1 from crossing into on-coming traffic during C1's attempt to run away. Staff member returned C1 to the facility and assessed C1 to ensure C1 was not hurt. Staff member reported incident to S1 and S2 immediately after it happened. Record review indicates, staff member has been working in the home for more than five years and has never been disciplined due to inappropriate behavior against clients in care. Staff member, has training in behavior management, de-escalation and redirection during behavioral crisis. Staff member continues with their employment at this facililty. S1-S2 further indicated, when they tried to talk to C1 about the reported abuse to provide with C1 with support, staff stated, C1 said they do not remember making a report to police. LPA was unable to interview C1 and staff member due to them not being at the facility at the time of visit; however, contact information was obtained.

No further action is required at this time. LPA Cota may return to gather additional documents and conduct additional interviews. No immediate health and safety risks were observed during visit. No deficiencies were cited during this visit. Exit interview was conducted with Jennifer Torres, Administrator and 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: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC809 (FAS) - (06/04)

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