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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603659
Report Date: 11/13/2025
Date Signed: 11/13/2025 04:28:25 PM

Document Has Been Signed on 11/13/2025 04:28 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:MINDFUL GROWTH CARE HOMESFACILITY NUMBER:
198603659
ADMINISTRATOR/
DIRECTOR:		FLOWERS, LONETTEFACILITY TYPE:
735
ADDRESS:1642 1/2 6TH AVETELEPHONE:
(310) 531-6049
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 0DATE:
11/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Staff Jasmine SampsonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA contacted licensee Jenero Jefferson via phone to inform licensee of today’s visit. Staff Jasmine Sampson arrived at 8:50 AM to help during visit. The purpose of today’s visit was explained. The facility is licensed to serve six (6) ambulatory adult clients Ages 18-59. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:
FACILITY PHYSICAL PLANT
The facility is a two-story residential building where the second-floor is licensed to care for clients. The facility has 3 bedrooms, 1 shared bathroom, a living room, dining room, kitchen, and laundry room. The facility does not have any clients in care as they are waiting to be vendorized through Frank D Lanterman Regional Center. There were no body of water observed in the property.
REVIEW OF FILES
Client files will be stored in a locked cabinet and administrator is aware that each client file must have the following documents on file – Admission Agreements, Identification and Emergency Information, medical consent form, current physician’s report, personal rights, pre-admission appraisal/appraisal needs and service plan or individual program plan (IPP). Facility has a designated area where staff files will be maintained. LPA reviewed only the Licensee files as there are currently no staff no issues were observed and within the file Administrator had the following: personnel report, criminal record clearance, health screening, current First Aid/CPR/CPI and sufficient on-going training, Licensee Certificate expired on 08/03/23. A deficiency is noted on LIC-809D to ensure that an active administrator is in place when the facility admits clients.

Report continues on LIC-809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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: MINDFUL GROWTH CARE HOMES
FACILITY NUMBER: 198603659
VISIT DATE: 11/13/2025
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Observations during facility tour:
  • LPA toured facility, bedrooms were furnished with a bedframe, dresser, lamps, and chairs.
  • The outdoor and passageways are free of obstruction. Wall and floors are in good repair.
  • Kitchen appliances were in working order and clean. There is no sufficient two (2) days of perishables and seven (7) day supply of non-perishable food since there are no clients residing at facility. Dining room has sufficient seating area.
  • Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
  • All storage areas for cleaning solutions, toxins, knives, and hazardous items will be kept in a locked and will be inaccessible to clients.
  • Smoke detectors and carbon monoxide detectors are operable and in compliance. One fire extinguisher is observed and is fully charged.
  • The facility maintains an approved fire clearance and plan to conduct fire drills as soon as staff are hired and once again once clients are admitted. Facility has an activity area furnished for outdoor use.
  • The facility has an Emergency Disaster Plan posted with contact numbers and at least 3 relocation sites. Facility will maintain documentation of the required emergency drills, however, no drills have been conducted as there is no staff or clients in care. Administrator aware that drills must be conducted once staff is hired and clients are admitted.
  • Smoke detectors were observed in all bedrooms and carbon monoxide detectors was observed in hallway in front bathroom.
  • The medications will centrally stored and locked in the closet room next to bathroom. LPA did not review medications since there are not clients in care,
  • LPA conducted interviews with one staff over the phone.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview held and copies of reports LIC 809, LIC 809D, and Appeal Rights were discussed and provided to staff Jasmine Sampson.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 04:28 PM - It Cannot Be Edited


Created By: Luis DeLeon On 11/13/2025 at 11:37 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: MINDFUL GROWTH CARE HOMES
FACILITY NUMBER: 198603659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
85064 Adminstrator Qualifications and Duties (b) All adult residential facilities shall have a certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above since administrator certificate has expired since 8/3/2023 and Administrator pending renewal list shows renewal pending since 11/2/2023. There is no active administrator certified at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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The licensee will provide CCLD with documentation needed for administrator renewal certificate by POC date. In addition, the licensee shall ensure that a certified administrator is in place by the time clients are readmitted to facility and send CCLD a change of administrator request before admitting clients.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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