198603714-4-14-2026-28-AS-MCOA-DT5UHV-20260414153633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603714
Report Date: 04/14/2026
Date Signed: 04/14/2026 03:37:29 PM

Document Has Been Signed on 04/14/2026 03:37 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:	FLORENTINES ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198603714
ADMINISTRATOR/ DIRECTOR:	TOMINES, JASMIN D.		FACILITY TYPE:	735
ADDRESS:	13339 CLOSE ST		TELEPHONE:	(626) 848-8836
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Eleonor Lopez, House Manager		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual inspection today. LPA met with Eleonor Lopez, House Manager, and the reason for the visit was explained. Jasmin Tomines, Administrator was informed regarding today’s visit and Lopez, continued to facilitate the inspection.

The facility is licensed to serve (4) developmentally disabled adults age 18 to 59; ambulatory only. The facility is operating within the scope of its license. The facility is currently providing services to clients through the Eastern Los Angeles Regional Center.

The single-story home is in a residential area of Whittier, and it consists of living room, dining area, kitchen, laundry room, (4) client bedrooms, (2) full bathrooms, attached garage, and front and backyard.

The following was observed during visit:

The facility was observed clean inside and out. Walkways, passageways and exits are kept clear of debris and obstructions. Furniture is clean and in good repair. Living and dining room have sufficient seating for staff and clients. The kitchen was observed clean and appliances were operating properly. The facility has a sufficient 2-day perishable and 7-day perishable supply of food. Dry and canned goods labeled and kept within expiration limits. Sharps/knives, cleaning supplies and other toxins are kept locked in a kitchen cabinet. Bedrooms have the required furniture, bedding and sufficient lighting. Bathrooms were also observed clean and sanitary. Water temperature was tested in bathroom #1 and #2 and measured 112.7 and 107.3 degrees F. which is within the compliance range of 105 - 120 degrees F. Bathrooms have safety grab bars and non-skid surfaces.

***Continues on LIC 809-C****

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

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: FLORENTINES ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198603714
	VISIT DATE: 04/14/2026

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Front and backyard are kept clean and garden is maintained. The backyard has a shaded patio area and patio furniture is in good repair. No pools or bodies of water were observed. The laundry area is kept clean, and appliances are in operating condition. The garage was observed free of clutter. The home has (1) fire extinguisher which is kept charged and operable. Smoke and carbon monoxide detectors were tested during visit and were operating properly. The facility conducts safety drills every month. Last safety drill was conducted on 4/1/2026, with client and staff participation. Closet in main entry way stores emergency supplies, PPE and First Aid kits.

Review of client medication was conducted. Medications are centrally stored in the dining area and were observed to be dispensed according to physician orders and documented accordingly. Four (4) client and (5) staff files were reviewed. Client files include Admission Agreement, Face sheet, Needs and Services/Individual Program Plan, Functional Capability Assessment, Physician’s Report and TB test result. Staff files have criminal the appropriate background clearances, First Aid/CPR certification, Health Screenings and training hours.

No deficiencies noted and no citations issued today. Exit interview was conducted with Eleonor Lopez, House Manager, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC809 (FAS) - (06/04)

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