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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 06/30/2026
Date Signed: 06/30/2026 04:05:10 PM

Document Has Been Signed on 06/30/2026 04:05 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:VILLA VICTORIAFACILITY NUMBER:
198603439
ADMINISTRATOR/
DIRECTOR:		INDRAWATI, YENNYFACILITY TYPE:
740
ADDRESS:1640 S. GLENDORA AVETELEPHONE:
(626) 888-7811
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
06/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Yenny IndrawatiTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff, and the purpose of visit was explained. Administrator Yenny Indrawati was notified and arrived shortly after.

This facility is licensed to serve residents ages 60 and over, three (3) non-ambulatory and three (3) ambulatory. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. The facility has a hospice waiver for five (5). There are currently zero (0) residents receiving hospice services. The facility is operating within the scope of their license.

The facility is a single-story home located in a residential area of Glendora. The home consists of living room, dining room, kitchen, 6 resident bedrooms, 3 bathrooms, laundry area and attached garage. The backyard has a newly constructed, vacant, ADU.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2026
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 10
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 06/30/2026 04:05 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 06/30/2026 at 02:08 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 in that LPA observed live roach activity in kitchen drawers, kitchen cabinets and on dining room table which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Licensee agreed to schedule pest control service to treat the facility for live roach/insect activity. Licensee agreed to submit to LPA via email the date of scheduled service by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in LPA observed Lispro Insulin injections in the refrigerator door, not in a locked place making them accessible to persons other than employees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Corrected at the time of visit. Licensee placed Lispro Insulin injections in a lock box and placed them back in the refrigerator.
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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2026 04:05 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 06/30/2026 at 02:08 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 in LPA observed pill boxes labeled with days of the week and residents names and 3 of 5 pill boxes contained pills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Corrected at the time of visit. Staff removed the pills and pill boxes.
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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2026 04:05 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 06/30/2026 at 02:08 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed did not contain TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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Licensee agreed to submit proof to LPA once TB clearance is obtained for S1. Licensee will submit proof via email by POC due date.

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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/30/2026 04:05 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 06/30/2026 at 02:08 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed were not maintained at the facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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Licensee will print documents and maintain a personnel record for the administrator at the facility.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents files reviewed did not contain functional capabilities assesment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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Licensee will complete the functional capabilities for 5 out of 5 residents and submit to LPA by POC due date.
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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/30/2026 04:05 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 06/30/2026 at 02:08 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files reviewed did not contain reappraisals which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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4
Reappraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. Licensee will submit to LPA via email a reappraisal for R4 by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 5 resident beds had half bed rails and no physician's orders for bedrails in their facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Corrected at time of visit. Staff removed bed rails from all residents beds. Licensee agreed to obtain physician's orders prior to using bed rails.
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:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


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: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 06/30/2026
NARRATIVE
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Combination smoke and carbon monoxide detectors were observed in the hallway, tested and are operable. All resident bedrooms contained required furniture, linens and lighting. Linens were clean and in good repair. LPA observed bedrails for 4 out of 5 residents but no physician orders for bedrails in place. Deficiency cited. Water temperatures in all grooming and bathing areas were measured below the required 105 – 120 degrees F. Licensee adjusted the water temperature at the time of visit. Technical advisory issued. LPA observed grab bars near toilets and showers and no-slip flooring and mats in the showers and bathtubs.

LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. LPA observed live roach and insect activity in kitchen drawers, cabinets and dining room table. Deficiency cited.

LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed a facility land line.

The facility has the Emergency Disaster Plan (LIC610D) in place. Last earthquake and fire drill was conducted 05/01/26. LPA observed facility sketches with exits and emergency exits routes throughout various locations of the facility.

No large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible.

Medications are centrally stored in a locked kitchen cabinet. LPA observed pilled boxes with pills, labeled with days of the week and residents’ names. Deficiency cited. LPA observed boxes of insulin injections in the refrigerator door, not in a safe and locked making them accessible to persons other than employees. Deficiency cited. The facility uses the Medication Administration Record (MAR) log to document medications given.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 06/30/2026
NARRATIVE
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Administrator Certificate for Yenny Indrawati and it expires 02/17/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

LPA reviewed two (2) staff files. Files were observed to contain required annual training, CPR and First Aid, Health screening, and fingerprint clearance for two (2) out of the two (2) personnel records reviewed. TB testing/clearance was not available for review for S1. Deficiency cited. Administrator did not have a file maintained at the facility available for review. Deficiency cited. LPA reviewed administrator’s documents via cell phone.

Facility has an Infection Control Plan in place.

LPA reviewed resident files for five (5) residents. Resident files are maintained at the facility. 5 out 5 resident files contained admission agreement, resident rights, medical assessment with TB clearance and pre-appraisals. 1 out of 5 files reviewed did not contain a reappraisal which should be updated in writing as frequently as necessary or once every 12 months. Deficiency cited. 5 out 5 files reviewed did not contain functional capabilities. Deficiency cited.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report, LIC809D and appeal rights were provided to Caregiver Luz Macalisang.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
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