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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003705
Report Date: 06/19/2025
Date Signed: 08/15/2025 08:42:01 AM

Document Has Been Signed on 08/15/2025 08:42 AM - 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:COACHMAN HOMEFACILITY NUMBER:
306003705
ADMINISTRATOR/
DIRECTOR:		RAFAEL TORRESFACILITY TYPE:
735
ADDRESS:9333 COACHMAN AVENUETELEPHONE:
(310) 567-9285
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 3DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:41 PM
MET WITH:Jacqueline Mikin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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***This is a corrected version of the original report. The purpose of the report is to correct a deficiency issued in error on the LIC 9099-D (section 84068.4(g)) which will be dismissed. On today's visit, LPA is issuing a citation under section 85068.4(g)***

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Required 1 year visit. LPA was granted entrance and met with Jacqueline MIkin, Administrator and the purpose of the visit was explained. There are (3) clients currently living in the facility.

The facility is licensed to serve (6) ambulatory developmentally disabled adults ages (18) to (59) years of age. The facility is operating within the scope of its licence. Clients in care receive services through the Eastern Los Angeles Regional Center. The facility is in a residential area of Whittier. The one story home consists of living room, dining area, kitchen, laundry room, (3) client bedrooms, (1) staff bedroom, (1) full bathroom, (1) half bathroom, detached garage and front and back yard.

During today's visit, the following was observed:

  • Facility is clean and walkways, ramps and staircases are free of debris and obstructions. Furniture throughout the facility was observed in good repair. There is sufficient seating in the living and dining area for clients. Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen. There is a closet in the hallway with extra clean linen, towels and personal hygiene products for clients.
  • Kitchen appliances were observed clean and were operating at the time of visit. Sharps are kept locked in the medication cabinet and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet under kitchen sink. Sufficient supply of 2 day perishable and 7 day non-perishable food was observed labeled and kept within expiration limits.

***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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 5
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: COACHMAN HOME
FACILITY NUMBER: 306003705
VISIT DATE: 06/19/2025
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  • Bathroom was inspected and was observed clean and sanitary. Shower in the bathroom has grab-bars. The water temperature was tested in the bathroom and measured at 119.3 degrees F which is within the required 105 - 120 degrees F. Laundry room appliances observed to be operable and detergents are kept locked in a cabinet.

  • The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to clients, located in the backyard. Patio furniture in the back yard was observed clean and in good repair. Garden is maintained and passageways and exits are free of obstruction. Garage is kept locked and inaccessible to clients.

  • Interconnected smoke detectors were observed throughout the facility and were tested and observed to be working properly. Carbon monoxide detector located in the dining area was also tested and was observed to be working properly. One (1) fire extinguisher located by the kitchen was observed charged and were last inspected on 4/26/25. Last fire/safety drill was conducted on 3/2/25. Fireplace in the living room is covered and is inaccessible to clients.

  • Two (2) staff and (3) client files were reviewed. however, age exemption request not present for the most recent client admitted who is above the age of (59). Medication observed centrally stored, locked and inaccessible to clients. Medication review was also conducted and medication was observed to be administered and documented accordingly per physician's orders.


Per California Code of Regulations, Title 22, and California Health and Safety Code, a deficiency is noted and cited during today's visit (see LIC 809-D). Exit interview held with Jacqueline Mikin, Administrator and a copy of the report and Appeal rights were provided at the time of visit. LPA also discussed with Administrator, 85068.4 Acceptance and Retention Limitations and printed and provided a copy of the regulations.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/15/2025 08:42 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/07/2025 08:05 AM


Created By: Mayra Cota On 06/19/2025 at 04:07 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COACHMAN HOME
FACILITY NUMBER: 306003705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
84068.4(g)
84068.4(g)
Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that Client 1 is the most recent client admitted that is above the age of (59), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Licensee will submit to LPA all required documentation (exemption) for Client 1 as noted on the above regulation.
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
This requirement is not met as evidenced by:


Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that Client 1 was the last client to be admitted to the facility over the age of 60, whereas the facility is already retaining one clients above the age of (60), which exceeds 50 percent of the census and poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Licensee, will submit to LPA all required documentation for an age exception for Client 1 as noted on the above regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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