198603460-6-30-2025-28-AS-SVAD-DJ5RNU-20250630131053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603460
Report Date: 06/26/2025
Date Signed: 06/30/2025 01:11:09 PM

Document Has Been Signed on 06/30/2025 01:11 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:	ST. SHARBEL'S GARVEY		FACILITY NUMBER:	198603460
ADMINISTRATOR/ DIRECTOR:	MUNZON, PETER		FACILITY TYPE:	735
ADDRESS:	2007 E GARVEY AVE N		TELEPHONE:	(562) 682-7027
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 6		CENSUS: 3	DATE:	06/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:19 PM
MET WITH:	Macristina Ilagan-Direct Staff Proffesional		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) S Vaid conducted an unannounced required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Macristina Ilagan DSP at the facility and was granted access into the home. Administrator Peter Munzon was unable to assist due to prior appointment. The facility is vendorized through the San Gabriel/Pomona Regional Center, there are three (3) clients residing. Two clients are at day program and one (1) client are home. 1. Infection Control: Facility has an infection control plan in place. The facility staff continues to practice hand washing and disinfect the facility at each shift and observed facility with sufficient PPE supplies. 2. Physical Environmental and safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: dining area, kitchen, living room, three client's bedrooms and two and half bathrooms, linen closet, staff office and a detached garage. The three client's bedrooms have two beds, two chairs, two drawers, night stands, required beddings and furniture and sufficient lighting and closet space. The two and half bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in those two and half bathrooms were tested between 109.8-113.6 F which is within Title 22 regulations. The sharp knives and utensils are stored and locked in the kitchen drawer. All the kitchen appliances are working properly. All the chemicals and cleaning supplies are stored and locked in the cabinet in the garage. The hallway light is usually on during the nighttime for client to access the non-private bathroom and the bathrooms have a night light too. LPA observed the carbon monoxide detectors, and they are interconnected, and they are working well. The facility has a telephone service on the premises. Continued on 809C........

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

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: ST. SHARBEL'S GARVEY	FACILITY NUMBER: 198603460
	VISIT DATE: 06/26/2025

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3. Operational Requirement: Facility is licensed for 5 ambulatory and 1 non-ambulatory in master bedroom only. The last fire drill was conducted on 01/08/25.
4. Staffing: Facility has sufficient staffing to provide care and supervision to the clients. LPA reviewed the NOC shift staff and they have the required the facility planned emergency procedure training.
5. Personnel Records-Training: All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. LPA inspected three staff files and they have the required documents in files. It's included: employment application, health screening with TB test result, required training hours and updated first aid certificate. The administrator is Peter Munoz and his administrator certificate is effective through 10/16/2026 and he has the required HIV and TB training.
6. Client's Right-Information: There's no client in the facility required any postural support. The facility has internet service and provide at least one internet access device that can support video conferencing with their family or doctor if needed.
7. Food Service: The facility has the required two days perishable and seven days non perishable food supply in the facility refrigerator, pantry and garage. All the food are stored properly. No client in the facility required any modified diet.
8. Client's Record-Incident Reports : All client's files are stored in the office. All client's files have all the required documents include: Face sheet, admission agreement, updated physician report, Individual Program Plan (IPP), ambulatory status and medication list.
9. Health Related Services: The facility medication is centrally stored and locked in the kitchen cabinet near the refrigerator. LPA inspected all client's medication and they are accurate and up-to-dated. The clients also have 30 days supply of medication. The facility would also assist and arrange client's medical and dental appointment. All staff also received the required training hours for medication management.
10. Incidental Medical Services: Currently there's one client is on restricted health condition care plan and LPA inspected client's file and all the required documents are placed in client's files and staff also had the required training. Facility does not have any client with prohibited health condition.
11. Disaster Preparedness: The facility has an Emergency Disaster Plan. The facility has two alternative shelter location.
12. Emergency Intervention: The facility does not use any restraints on clients.

No deficiencies were observed during the annual inspection visit.
Exit Interview and a copy of the report was provided to Virelina Elopre, Direct Staff Professional.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

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