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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603531
Report Date: 09/04/2025
Date Signed: 09/04/2025 12:08:01 PM

Document Has Been Signed on 09/04/2025 12:08 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:FAIR OAKS MANORFACILITY NUMBER:
198603531
ADMINISTRATOR/
DIRECTOR:		MARYCEL CAMPOSFACILITY TYPE:
735
ADDRESS:1753 N. FAIR OAKS AVE.TELEPHONE:
(626) 345-9788
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 14CENSUS: 11DATE:
09/04/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Rodolfo Gonzales, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Rodolfo Gonzales, Direct Care Staff and explained the purpose of the visit. Marycel Campos, Administrator, arrived shortly after and LPA explained the purpose of the visit. The facility is licensed to care for (14) Developmentally Disabled Adults, ambulatory, of which (2) may be non-ambulatory, ages 18 through 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center.

The initial annual visit was conducted on 09/02/2025. During the initial visit the following four (4) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Physical Plant Environmental Safety, Client Rights-Information, Food Services, and Health-Related Services.

During today’s annual visit, the following eight (8) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Staffing, Personnel Records-Training, Client Records-Personnel Reports, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.

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



Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. The facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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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 09/04/2025 12:08 PM - It Cannot Be Edited


Created By: Daniel Konishi On 09/04/2025 at 11:55 AM
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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that the Staff #3 (S3') file did not have a Health Screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will send Staff #3 (S3's) Health Screening to the LPA by POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that the Staff #3 (S3's) file did not have a TB test clearance in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will send Staff #3 (S3's) TB test clearance to the LPA by POC due date.
Daniel.Konishi@dss.ca.gov
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:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


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: FAIR OAKS MANOR
FACILITY NUMBER: 198603531
VISIT DATE: 09/04/2025
NARRATIVE
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Operational Requirements: A fire clearance is in place. LPA reviewed valid Liability Insurance in place. LPA reviewed the valid Surety Bond in place. The last fire drill was conducted on 8/29/2025 and the earthquake drill was conducted on 8/29/2025.

Staffing: A total of none (9) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: LPA reviewed five (5) staff files which include: Personnel Record, Criminal Background Clearance, Health Screening, TB Clearance, Employee Rights, valid First Aid / CPR training, Medication Administration Training, and Staff Training. The Administrator certificate is valid and expires on 12/23/2026. The administrator has a valid HIV and TB training certificate in file. However, based on a record review, Staff #3 (S3’s) file did not have the Health Screening and TB test clearance.

Client Records-Incident Reports: LPA reviewed five (5) client files which include: Face Sheet, Physician's Report (including TB and Ambulatory Status), Individual Program Plan (IPP), Appraisal / Needs and Services Plan, Client Personal Property and Clients Personal Rights observed.

Incidental Medical Services: There is one (1) client at this home has a restricted health condition and the facility has a Restricted Health Condition Plan in place.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. The last fire/earthquake drill was conducted on 08/29/2025.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Marycel Campos.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
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