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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603779
Report Date: 11/25/2025
Date Signed: 11/25/2025 12:50:14 PM

Document Has Been Signed on 11/25/2025 12:50 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:ALTAPAS CARE CENTERFACILITY NUMBER:
198603779
ADMINISTRATOR/
DIRECTOR:		GALEANO, DAYSIFACILITY TYPE:
735
ADDRESS:2011 N. SUMMIT AVETELEPHONE:
(626) 823-6117
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 3DATE:
11/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Daysi Galeano, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with the Licensee, Gary Hall and Administrator, Daysi Galeano who assisted LPA with the visit.

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

Infection Control: The facility has an Infection Control Plan in place. Emergency Disaster Plan is current and posted. Staff will adhere to infection control requirements.



Physical Plant & Environment Safety: The facility is a single-story home in a residential neighborhood. It contains three (3) bedrooms, two and a half (2 1/2) bathrooms, a living room, kitchen, dining area, laundry area, backyard, and basement. A separate house in the back securely fenced and with a different address. Bedrooms are large enough to allow for easy passage and have the required items of furniture. There are 2 1/2 bathrooms in the home that have grab bars and non-skid mats in the shower room. There are sufficient supply of towels and linens are available to permit weekly changing are available. Sufficient personal hygiene supply available. Smoke/Carbon monoxide detectors were observed throughout the home and were tested and operable. Fire extinguisher was observed and fully charged. Cleaning solutions and sharps were locked and stored separately from where food supplies are stored. Hot water temperature readings were within the Title 22 Regulations requirement. Between 9:45am-10:02am, hot water readings were as follows: bathroom #1 at 111.3 deg F, bathroom #2 at 116.7 deg F and ½ bathroom at 111.7 deg F. The backyard has a shaded area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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: ALTAPAS CARE CENTER
FACILITY NUMBER: 198603779
VISIT DATE: 11/25/2025
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Operational Requirements: Fire clearance granted for four (4) ambulatory, two (2) non ambulatory and (0) bedridden. Valid Surety bond is in place. Valid Liability Insurance is in place. One (1) operating telephone was observed and tested on the premises.

Staffing: A total of fifteen (15) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: LPA reviewed four (4) staff files which include: personnel record, health screening, TB Clearance, 1st Aid/CPR training, Administration of Medication, and ongoing staff training. Administrator certificate is valid and expires on 01/15/2026. Administrator has valid HIV/AIDS training. However, LPA reviewed Staff #2 (S2’s) file which was missing the health screening and valid First Aid Training.

Client Rights-Information: Client personal rights are posted. Facility has internet service accessible to all clients. Working facility phone is available and accessible to clients.

Client Records-Incident Reports: LPA reviewed three (3) client files which include Face sheet, Identification and Emergency Information, Admission Agreement, Physician's Report (including TB and Ambulatory Status), IPP (Individual Program Plan, Pre-Placement Appraisal, Appraisal/Needs and Services Plan, Clients Personal Rights, and Centrally Stored Medication Destruction Record.

Food Service: LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas.

Health Related Services: The medications will be centrally stored and locked in the kitchen cabinet. LPA reviewed medication for three (3) clients. Medications are administered as prescribed by the Physician. First aid kit was inspected and observed to be fully stocked.

Incidental Medical Services: There are no clients at this home with incidental medical services nor have a restricted health condition.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: ALTAPAS CARE CENTER
FACILITY NUMBER: 198603779
VISIT DATE: 11/25/2025
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Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Last Fire Drill was conducted on 07/22/2025. Last Earthquake/Disaster drill was conducted on 10/10/2025.

Emergency Intervention: The facility does not use any restraints or seclusion.

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 Licensee, Gary Hall.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/25/2025 12:50 PM - It Cannot Be Edited


Created By: Daniel Konishi On 11/25/2025 at 12:38 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: ALTAPAS CARE CENTER
FACILITY NUMBER: 198603779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed Staff #2 (S2’s) file which did not have the health screening in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Administrator will send Staff #2 (S2's) health screening to the LPA by POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed Staff #2 (S2's) file which did not have valid first aid training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2025
Plan of Correction
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Administrator will send Staff #2 (S2's) valid first aid training to the LPA by POC due date.
Daniel.Konishi@dss.ca.gov
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:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2025


LIC809 (FAS) - (06/04)
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