<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603702
Report Date: 08/13/2026
Date Signed: 08/19/2026 12:05:48 PM

Document Has Been Signed on 08/19/2026 12:05 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 CECILIA'S SENIOR HOMEFACILITY NUMBER:
198603702
ADMINISTRATOR/
DIRECTOR:		VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:1005 FOUNTAIN SPRINGS LN.TELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
08/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:Tiffany Vander Poorten, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:25 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) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff and informed of the purpose of the visit. Administrator Tiffany Vander Poorten arrived shortly thereafter.

The facility’s fire clearance is approved for six (6) non-ambulatory residents ages 60 and older. The facility also holds a hospice waiver for six (6) residents. At the time of the inspection, two (2) residents were under hospice care.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is located in a residential neighborhood and is a single-story home consisting of four (4) resident bedrooms, one (1) caregiver corridor within the garage, two (2) bathrooms, a living room, family room, kitchen, dining area, attached garage,laundry room, front yard, and backyard. All bedrooms observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a kitchen drawer, and cleaning supplies were secured in the locked laundry room and kitchen cabinet. Bathrooms were observed to be clean and equipped with required grab bars near showers and toilets, as well as non-skid mats. Hot water temperature was observed outside the required regulatory range of 105°F–120°F. Extra linens and towels were available and stored in hallway and restroom cabinets. Smoke and carbon monoxide detectors were tested and found operational. Fire extinguishers were observed and available. No bodies of water were present on the premises. The backyard and front yard contained shaded seating for residents. Passageways and exits were observed to be clear and unobstructed. (continued on 809C)

David Sicairos
Gabriela Castro
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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)
Page: 2 of 6
Document Has Been Signed on 08/19/2026 12:05 PM - It Cannot Be Edited


Created By: Gabriela Castro On 08/13/2026 at 12:30 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: ST CECILIA'S SENIOR HOME
FACILITY NUMBER: 198603702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

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
1
2
3
4
Based on observation and record review, S5 and S6 did not have TB test results on file. The licensee failed to comply with the section cited above in two (2) out of six (6) staff files reviewed (S5 and S6). which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Administrator to provide proof of TB test for S5 and S6 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/19/2026 12:05 PM - It Cannot Be Edited


Created By: Gabriela Castro On 08/13/2026 at 12:30 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: ST CECILIA'S SENIOR HOME
FACILITY NUMBER: 198603702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, S3 did not have a criminal record clearance on file. Follow-up was conducted with Guardian, and there are pending steps to be completed by the Administrator. The licensee did not comply with the section cited above in one (1) out of six (6) staff files reviewed (S3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Administrator to submit a plan detailing how the facility will ensure all employees have a criminal record clearance and are associated with the facility prior to beginning work and providing care to residents. Administrator will also follow up by the POC due date regarding the instructions provided by Guardian during the LPA’s visit and provide LPA with a copy of S3’s criminal record clearance and facility association.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
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 CECILIA'S SENIOR HOME
FACILITY NUMBER: 198603702
VISIT DATE: 08/13/2026
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
26
27
28
29
30
31
32
Food Service

Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were stocked.

Health-Related Services & Records

Four (4) resident files were reviewed. Files contained current required documentation, including Admission Agreements, signed consents, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments. A Technical Advisory will be issued for not having current Needs and Services Plans on file.

Three (3) residents’ medications were reviewed. Medications were observed to be centrally stored in a kitchen cabinet room area.

Disaster Preparedness

Last fire/earthquake drill was conducted on July 8, 2026, with logs available. LIC 610D Emergency Disaster Plan was in process of being updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed.

Personnel Records & Training

Six (6) staff files were reviewed and included CPR/First Aid and required training. TB test results were not on file for S5 and S6. S3 was missing documentation of a criminal record clearance, and follow-up was conducted during the visit. Administrator Certificate for Tiffany Vander Poorten was valid through August 25, 2026.

An exit interview was conducted with Tiffany Vander Poorten. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/19/2026 12:05 PM - It Cannot Be Edited


Created By: Gabriela Castro On 08/13/2026 at 01:06 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: ST CECILIA'S SENIOR HOME
FACILITY NUMBER: 198603702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:

Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above in one (1) out of four (4) R2 was observed to have full bed rails without that exception and resident was not on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Administrator to submit and exception request for full bed rails for R2 by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6