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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603483
Report Date: 10/05/2026
Date Signed: 10/05/2026 03:35:21 PM

Document Has Been Signed on 10/05/2026 03:35 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:ASSISTED LIVING & WELLNESS - NAOMIFACILITY NUMBER:
198603483
ADMINISTRATOR/
DIRECTOR:		SANDOVAL, JENNIFERFACILITY TYPE:
740
ADDRESS:220 W. NAOMI AVETELEPHONE:
(626) 315-2561
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 6CENSUS: 6DATE:
10/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Kenny Yu - Licensee
Margaret Grancich - LVN		TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Kristina Brown and Rita Flores, Caregivers and explained the purpose of the visit. Shortly after, Kenny Yu, Licensee and Margaret Grancich, LVN arrived to assist LPA. The facility is approved to serve residents age range 60 and above, approved for (1) ambulatory and (5) bedridden in room numbers 1, 2, 3, 5 and 6 only. Hospice waiver approved for (6). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are trained in the proper use of all required PPEs prior to being around residents. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.


Operational Requirements: Facility has signal systems in exit points. The facility has a dementia care plan to accept or retain residents with dementia. Staff have the required training to provide special care to dementia residents. Staff cannot provide a copy of the liability insurance during the visit.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (6) resident bedrooms, (3) bathrooms, living room with covered fireplace, family room, kitchen, dining room, laundry area and backyard with patio area. There are currently (6) residents, 60 years and older residing in the facility, (5) are under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and has a covered patio area. There are (2) fire extinguishers in the facility which were serviced on 04/21/2026. Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit *****REPORT CONTINUED ON LIC809-C*****
Lisa Hicks
Bennette Pena
DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2026
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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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: ASSISTED LIVING & WELLNESS - NAOMI
FACILITY NUMBER: 198603483
VISIT DATE: 10/05/2026
NARRATIVE
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Staffing: A total of (33) staff including the Licensee and Administrator provide care and supervision to the residents. One (1) staff provides night supervision and can assist in caring for residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Staff files were reviewed for criminal background clearance and training. (2) of (3) Personnel records reviewed have health/TB screenings. Administrator has a valid Administrator certificate, expires on 07/22/2027.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Facility provides initial and ongoing training for staff.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities.
Residents are encouraged to participate in a variety of planned activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses Electronic Medication Administration Record (EMAR) log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents. First-aid supplies along with a manual are maintained in the facility.
Resident Records-Incident Reports: Resident files were reviewed containing Admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance and Personal rights.
Disaster Preparedness: The facility has Emergency Disaster Plan. LVN stated that staff had fire drill training, however, the in service training log could not be found.
Residents with SHN: (5) residents are under hospice care and one resident on oxygen. Physician orders for 1/2 bed rails could not be found on the residents' files. Training records for staff, including dementia and oxygen training cannot be located in the facility.

Deficiencies cited and Technical assistance issued. Exit interview and a copy of this report along with the appeal rights were provided to Margaret Grancich, LVN.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/05/2026 03:35 PM - It Cannot Be Edited


Created By: Bennette Pena On 10/05/2026 at 02:54 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: ASSISTED LIVING & WELLNESS - NAOMI
FACILITY NUMBER: 198603483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

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 that Staff #2 (S2’s) file did not have a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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The administrator/licensee will send proof of Staff #2 (S2’s) health screening to CCLD/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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2026 03:35 PM - It Cannot Be Edited


Created By: Bennette Pena On 10/05/2026 at 02:54 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: ASSISTED LIVING & WELLNESS - NAOMI
FACILITY NUMBER: 198603483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on interview, record review, the licensee/administrator did not comply with the section cited above in that there were no documented staff training including dementia, fire drill and oxygen training in the staff files/records which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/12/2026
Plan of Correction
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Administrator/licensee to submit proof of staff training including, fire/emergency drill, dementia and oxygen training to CCLD/LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the administrator/ licensee did not comply with the section cited above in that the physician's authorizations for 1/2 bedrail for all (5) residents were missing from the residents' files which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 10/12/2026
Plan of Correction
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Administrator/licensee will submit the physicians order/authorizations for 1/2 bedrails for (5) out of (6) residents and send them to CCLD/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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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