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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603877
Report Date: 02/23/2026
Date Signed: 02/23/2026 03:22:48 PM

Document Has Been Signed on 02/23/2026 03:22 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:CLAYTON COTTAGE 1FACILITY NUMBER:
198603877
ADMINISTRATOR/
DIRECTOR:		CLAYTON, CAMERONFACILITY TYPE:
735
ADDRESS:1576 N EL MOLINO AVETELEPHONE:
(626) 794-3351
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
02/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Ebony Gilcres, DSPTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit today. LPA met with Ebony Gilchrest, DSP and the reason for the visit was explained. Cameron Clayton, Administrator, arrived shortly and continued facilitating the visit.

The facility is licensed to serve (6) ambulatory only clients, ages 18 to 59. The facility is operating within the scope of its license. Clients in care are provided services through the San Gabriel/Pomona Regional Center. There are currently (6) clients living in the facility.

The single-story home is in a residential area of Pasadena. The physical plant consists of living room, dining area, (5) client bedrooms, (1) staff office, (2) full bathrooms, detached garage with a laundry room, 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 area 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. Sharps/knives, cleaning supplies and other toxins are kept locked in the staff office. Bedrooms have all 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 108.7 and 108.3-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: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2026
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 3
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: CLAYTON COTTAGE 1
FACILITY NUMBER: 198603877
VISIT DATE: 02/23/2026
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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. Facility has extra supply of personal hygiene and incontinence care items readily available for use. The home has (2) fire extinguishers, charged and operable, and were last inspected on 2/6/2026. Combination smoke and carbon monoxide detectors were tested during visit and were operating properly. The facility conducts safety drills every two months. Last safety drill was conducted on 12/12/2025, with client and staff participation. Medication reviews for (3) clients were conducted and medications were observed to be dispensed according to physician orders and documented accordingly. Six (6) client and (4) staff files were reviewed and all required documents were present and up to date.

No deficiencies noted and no citations issued today. Exit interview was conducted with Cameron Clayton 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: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC809 (FAS) - (06/04)
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