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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603201
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:55:25 AM

Document Has Been Signed on 10/16/2025 11:55 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: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: 4DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Idalia Guardado, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Idalia Guardado, Direct Support Professional and the reason for the visit was explained. Jennifer Torres, Administrator, arrived thereafter and continued to facilitate the visit.

The facility is licensed to serve developmentally disabled adults, age range 18 through 59, six (6) ambulatory only. The facility is operating within the scope of its license. Clints in care are provided services through the Frank D. Lanterman Regional Center. The facility is in a residential area of Pasadena. The single-story home consists of living room, dining room, kitchen, laundry room, (3) client bedrooms, (2) full bathrooms, quiet room, staff locker area, office, front and backyard, patio area and detached garage/activity area.

During today’s visit, LPA toured the home and observed the following:

Facility was observed clean inside and out. Walkways, passages and exists are free of debris and obstructions. Living room and dining area have sufficient seating for clients and staff and furniture is in good repair. Facility has a fireplace; however, fireplace did not have a cover during inspection of the home. Kitchen appliances were observed clean and operable; however, grease stains were observed between the stove and a food cabinet. Facility has sufficient 2-day perishable and 7-day non-perishable supply of food which is kept labeled and properly stored. Fruit was observed in a caddy in the kitchen for clients in care. Sharps/knives and cleaning supplies are kept locked in the kitchen and inaccessible to clients. Bedrooms were observed clean and have the required furnishing and bedding. Both bathrooms were also observed clean and sanitary. Water temperature was tested in the bathrooms and measured at 108.3 and 106.7, which is within compliance range. Laundry appliances are in good repair and detergents are kept locked.

***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: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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Document Has Been Signed on 10/16/2025 11:55 AM - It Cannot Be Edited


Created By: Mayra Cota On 10/16/2025 at 11:22 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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

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 by not having a cover over the fireplace which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2025
Plan of Correction
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Licensee/Administrator will purchase a fireplace cover and send LPA a copy of purchase receipt and a photo of installed fireplace cover by POC due date (via email or text message).
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


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: HEART TO HOME RESIDENTIAL FACILTY
FACILITY NUMBER: 198603201
VISIT DATE: 10/16/2025
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The front and backyard are well maintained and free of debris. The backyard has three storage sheds which are kept locked and inaccessible to clients. Backyard has a shaded patio area and patio furniture is in good repair. Detached garage houses a client activity area which was observed clean and stocked with games and other leisure materials.

During visit, (4) client and (3) staff files were reviewed. Client files contain admission agreements, Physician Reports, medical/functional assessments, Appraisals/Needs and Services Plans, TB clearance, personal rights and consent forms. Staff files contain health screenings, criminal background clearances and training documentation.

Medication for (3) clients was reviewed and found to be administered according to physicians’ orders and documented accordingly. Medication is kept centrally stored, locked and inaccessible to clients. Facility keeps PPE supplies in a closet in the quiet room. Emergency and Disaster Plan (LIC 610-D) is posted and kept up to date. Facility conducts safety/fire drills every month. Last drill was conducted on 10/15/25 with staff and client participation. Facility has (3) fire extinguishers charged and operable. Fire extinguishers were last serviced on 2/29/25. Combination smoke and carbon monoxide detectors were tested and were working properly.

During today’s visit, a deficiency is cited and a technical violation issued, per California Code of Regulations, Title 22, and California Health and Safety Code. Exit interview was conducted with Jennifer Torres, Administrator, and a copy of the report and Appeal Rights were provided.

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

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
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