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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603738
Report Date: 03/09/2026
Date Signed: 03/09/2026 12:17:43 PM

Document Has Been Signed on 03/09/2026 12:17 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:DIVINE VILLAFACILITY NUMBER:
198603738
ADMINISTRATOR/
DIRECTOR:		LIBANG, LEILANIFACILITY TYPE:
734
ADDRESS:244 ANDOVER DRTELEPHONE:
(909) 841-6315
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 5CENSUS: 4DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Liezl Tuason, Backup Admin. TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Jonathan Vanmou, LVN and explained the reason for the visit. Facility Backup Admin. Liezl Tuason arrived shortly thereafter.

This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is serviced by San Gabriel/Pomona Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden.

FACILITY TOUR AND OBSERVATIONS:

Personal Rights postings were observed in a common areas. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. During today’s visit, LPA observed four (4) staff members providing direct care and supervision to clients in care.

Physical Plant

The facility is a single-story home that contains five (5) bedrooms, three (3) bathrooms, a living room, TV room, dining room, laundry room, backyard shaded patio area, and an attached garage. All five (5) bedrooms are equipped with mechanical lifts. Of the three (3) bathrooms, one (1) bathroom is equipped with a mechanical lift. All five (5) bedrooms contained the required furniture and adequate lighting. Water temperatures were measured as follows: Bathroom #1 measured at 116.7°F; Bathroom #2 measured at 117.3°F; and Restroom #3 (staff restroom) measured at 117.4°F. The mechanical lift in Bathroom #1 was tested and found to be operable during the visit. LPA also observed a shower gurney in Bathroom #1. All client bathrooms were observed to be clean, and signs promoting proper hand washing were posted. Smoke and carbon monoxide detectors were tested and found to be operational. Charged fire extinguishers were observed throughout the facility. Oxygen use signs were posted throughout the facility. All exits were clear of obstruction, and no bodies of water were observed on the premises. In the laundry area, laundry soap and supplies were stored in a manner that made them inaccessible to the four (4) clients in care. The attached garage was observed to contain a generator, which was tested during the visit. Emergency water, food, and disaster supplies were also observed stored in the garage.

(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
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: DIVINE VILLA
FACILITY NUMBER: 198603738
VISIT DATE: 03/09/2026
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Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees F and freezer 0-degree F) with sufficient supply of 2-day perishable and 7 days non-perishable food. Knives and cleaning supplies are locked in a locked cabinet and drawer in the kitchen and are inaccessible to clients.

Health-Related Services & Records:
Four (4) client files were reviewed and contained current required documents (Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status, Rights acknowledgments, and IPPs). Medical/dental care was current. Four (4) medications were reviewed; medications are centrally stored in locked cabinet in the garage, locked, and labeled. MAR logs were current.

Disaster Preparedness:
Last fire/earthquake drill was conducted on February 5, 2026. Various logs reflect monthly drills with staff on various shifts. LIC 610D Emergency Disaster Plan was obtained and copy was collected for facility file. Emergency supplies (water, food, flashlights, batteries, first aid) were observed.

Personnel Records & Training:
Four (4) staff files were reviewed and included criminal record clearances, CPR/First Aid, DSP training, and TB screenings. Administrator Certificate for Leilani Libang was valid through February 06, 2027. Staffing ratio met requirements.

Liability Insurance:
Liability insurance was in compliance with an expiration March 3, 2027.

An exit interview was conducted with Liezl Tuason,Backup Admin. During the inspection, the facility was observed to be following Title 22, Division 6 regulations. No deficiencies were cited at this time. A copy of the report was provided.

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

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
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