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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603457
Report Date: 07/23/2026
Date Signed: 07/23/2026 02:32:22 PM

Document Has Been Signed on 07/23/2026 02:32 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:AYANNA HOME CAREFACILITY NUMBER:
198603457
ADMINISTRATOR/
DIRECTOR:		MATE, KELVINFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(562) 232-3034
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 6CENSUS: 5DATE:
07/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:23 PM
MET WITH:Elizabeth RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Elizabeth Rodriguez and explained reason for visit. Administrator Elba Rodriguez was notified by telephone and stated she was attending a personal matter.

Facility is licensed to serve six (6) non-ambulatory residents age 60 and over. The facility may retain three (3) hospice residents. The facility is in a residential area. A tour of the facility included the living room, kitchen with dining area, 4 resident bedrooms, 2 bathrooms, attached garage, and outside shaded area for residents.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. LPA observed one resident with full bed rails and no hospice plan available. Room #2 had a mattress and bed rails on floor. The Smoke /carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has three (3) fire extinguishers that were serviced on 07/21/2026. Cleaning supplies and toxic substances were observed to be accessible under kitchen sink at time of visit. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility was observed to have sufficient supply of 2 days perishable & 7 days non-perishable foods. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents outside. Passageways and exits are free of obstruction.

LPA was unable to review Administrator, staff/staff training, and resident files due to staff having no access to documents and Administrator being away and not having an authorized designee. Facility did not have dementia plan of operation available at time of visit along with required Liability Insurance. LPA requested a copy of infection control plan, emergency disaster plan, and emergency drills conducted at facility. LPA could not conduct a medication check due to staff not having a list of prescribed medication from physician with dosages at time of visit.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Elizabeth Rodriguez.

David Sicairos
Christian Gutierrez
DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2026
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 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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 infection control plan was not avaliable at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will email LPA infection control plan by POC due date.
Type B
Section Cited
CCR
87706(a)
Advertising Dementia Special Care, Programming, and Environments
(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements:

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 Administrator did not have dementia plan of operation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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LPA had requested plan of operation since 12/19/2025 and still has not received. Administrator will sent 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 liquid dishwashing soap,kleenking stainless steel copper cleaner,and zevo bug spary unlocked under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Staff removed cleaners at time of visit. Administrator will conduct training with staff and send to LPA by POC due date.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 R5 had full bed rails with no hospice care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Administrator will remove bed rails and send LPA picture or provide hospice care information 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by 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 facility did not have a medication log with prescribed by physician with dosage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will send log to LPA by POC due date for all 5 residents.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 residents files were not avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will send 5 resident files 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above personnel files were not available during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will send files for 3 staff and Admin file toLPA by POC due date.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above staff training was not avaliable at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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3
4
Administrator will send all required training for staff 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility did not have liability insurance at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will email LPA INS by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above room two had bed rails/mattress on floor of room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Administrator will send pictures as proof of items removed in bedrooms 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 07/23/2026 02:32 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/23/2026 at 01:43 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: AYANNA HOME CARE
FACILITY NUMBER: 198603457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above emergency disaster plan was not avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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2
3
4
Administrator will send updated emergency disaster plan to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility did not have any drills avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
1
2
3
4
Administrator will send drills 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
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