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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603368
Report Date: 03/04/2025
Date Signed: 03/04/2025 03:54:55 PM

Document Has Been Signed on 03/04/2025 03:54 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:FOXDALE HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603368
ADMINISTRATOR/
DIRECTOR:		TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:540 N. FOXDALE AVETELEPHONE:
(626) 337-7782
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:48 PM
MET WITH:Olivia Tomines, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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A Case Management visit was conducted during the course of the investigation of a complaint received by Regional Office by Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez. The following deficiency :

Licensee did not comply with reporting requirements. The deficiency cited is documented on the LIC 809-D.

Exit interview held with Olivia Tomines, Administrator and Appeals Rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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Document Has Been Signed on 03/04/2025 03:54 PM - It Cannot Be Edited


Created By: Mayra Cota On 03/04/2025 at 02:06 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: FOXDALE HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2025
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: Any unusual incident or client absence which threatens the physical or emotional health or safety of any client...

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Licenseeshall ensure that all Unusual Incident Reports (SIR's) are reported to CCL and all other necessary departments within 24 hours of incident occurring and/or submit a written report to CCL within 7 days of the occurrence of any reportable events. Submit a written plan and proof of staff training regarding incident report reporting requirements.

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This requirement was not met as evidence by: Licensee did not report incident regarding client on client physical aggression on 2/15/25 to CCL which poses a potential health and safety risk for clients in care.
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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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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