198603615-5-28-2026-28-AS-BGOZ-DUJ2BF-20260528171505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603615
Report Date: 05/28/2026
Date Signed: 05/28/2026 05:15:15 PM

Document Has Been Signed on 05/28/2026 05:15 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:	WORKMAN LANE		FACILITY NUMBER:	198603615
ADMINISTRATOR/ DIRECTOR:	SMITH, JASON K.		FACILITY TYPE:	735
ADDRESS:	647 E. WORKMAN LANE		TELEPHONE:	(626) 714-3100
CITY:	COVINA	STATE: CA	ZIP CODE:	91723
CAPACITY: 4		CENSUS: 4	DATE:	05/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:26 PM
MET WITH:	Cindy Garcia Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

NARRATIVE

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose for the visit was explained.

The facility is a single-story home located in a residential neighborhood area in Covina. The home consists of a living room, dining area, kitchen, four client bedrooms, 2 bathrooms, attached garage with washer and dryer, and front and back yards. The facility is licensed to serve four (4) adults ages 18-59 of which three (3) may be non-ambulatory. 2 out of 4 clients in care are over the age of 59. Bedrooms#2, #3, #4 are for non-ambulatory. Three (3) clients receive services as Level 4 Specialized (Deaf and Hard of hearing) Home through the San Gabriel/Pomona Regional Center. One (1) client is receives services as Level 4 Specialized (Deaf and Hard of hearing) Home through the Kern County Regional Center.

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

The client bedrooms have, for each client, one bed, one chair, one drawer, one night stand, required furniture and beddings and sufficient lighting and closet space. The hot water temperature was tested in the bathrooms and measured within the required 105°f -120°F.

continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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: WORKMAN LANE	FACILITY NUMBER: 198603615
	VISIT DATE: 05/28/2026

NARRATIVE

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LPA observed the kitchen to be clean and sanitary and free of pests. The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored properly. Currently there's no client in the facility is on any modified diet. Sharp knives and utensils are stored and locked in the file cabinet near the kitchen. All the kitchen appliances are working well. All the chemicals and cleaning supplies are stored and locked in a hall closet. Carbon monoxide detector was observed in the hallway, was tested and is operable. Fireplace has a secure enclosure and is inaccessible to clients. The passageway, walkway and patio are free of obstruction. The backyard has a covered patio with chairs and table for client to utilize the outdoor activity.

The last fire drill was conducted on 05/12/2026. The last earthquake drill was conducted on 04/06/2026. Fire extinguisher located in the kitchen, garage and hallway.

LPA reviewed four (4) staff files. Files were observed to have the required documents which included: personnel record, health screening, TB Test result, required training hours, and valid first aid certificate.

LPA reviewed four (4) client files. Files were observed to have the following required documents: face sheet, admission agreement, Updated Individual Program Plan (IPP), updated physician report, personal rights, and ambulatory status.

The client's medication is stored and locked in the file cabinet near the kitchen. LPA reviewed client's medication and were observed to be documented and dispensed as directed. LPA reviewed the first aid kit, and they have all the required supplies in the kit.

Facility has an updated and complete Emergency Disaster Plan (LIC610D) in place. The facility has two alternative shelter location. LPA advised administrator to include a location outside of their immediate area.

All the facility staff are CPI trained and they all have updated CPI certificate in file but they haven't been used CPI /restrain on client.

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 Cindy Garcia.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/28/2026 05:15 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 05/28/2026 at 04:55 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: WORKMAN LANE	FACILITY NUMBER: 198603615
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80010(a)

Limitations on Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. 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 in 2 out of 4 clients in care are over the age of 59 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	Administrator agreed to submit to LPA documents required to request an age exception for the two clients.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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