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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003747
Report Date: 08/04/2026
Date Signed: 08/04/2026 03:23:15 PM

Document Has Been Signed on 08/04/2026 03:23 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:MAPLE HOMEFACILITY NUMBER:
306003747
ADMINISTRATOR/
DIRECTOR:		ROMMEL P. GONZALESFACILITY TYPE:
735
ADDRESS:9435 MAPLE STREETTELEPHONE:
(562) 867-4235
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:51 PM
MET WITH: Catalina Ona, DSPTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with the DSP (Direct Support Professional), Catalina Ona and LPA explained the reason for the visit. Administrator Rommel Gonzales arrived shortly after to assist with the visit. The facility is licensed to serve (4) Ambulatory Adults, ages 18 through 59. Facility currently has four (4) Ambulatory clients serviced by Harbor Regional Center.

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

Infection Control: The facility maintains the required Infection Control Plan. Hand sanitizing and infection prevention were observed at the facility.

Physical Plant & Environment Safety: The facility is a single-story home located in a residential area which includes a living room, dining area, kitchen, one (1) staff bedroom with bathroom , four (4) client bedrooms, one (1) bathroom, laundry area, detached garage, front yard and back yard, with one (1) locked storage shed. LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The backyard also has a shaded area for activity purposes. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested at 106.8 degrees F, which was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a fire extinguisher that is fully charged and last inspected on 1/28/2026.

David Sicairos
Daniel Konishi
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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: MAPLE HOME
FACILITY NUMBER: 306003747
VISIT DATE: 08/04/2026
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Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview and a copy of this report was provided to the Administrator Rommel Gonzales.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MAPLE HOME
FACILITY NUMBER: 306003747
VISIT DATE: 08/04/2026
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Operational Requirements: Facility has a fire clearance. The facility has a valid Surety Bond and valid Liability Insurance in place. Last Fire Drill was conducted on 07/01/2026.

Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.

Personnel Records - Training: LPA reviewed five (5) staff that includes Personnel Record, Health Screening, TB Clearance, Employee Rights, 1st Aid/CPR/AED training, and Staff Training. Administrator certificate is valid and will expire on 03/21/2028. Administrator has a updated HIV/TB training in file.

Client Rights - Information: Clients rights and other posters were observed posted throughout the home. A device with internet access is available.

Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. Sufficient food supplies were observed for at least two (2) days of perishables and seven (7) days of non-perishables. Per Administrator, no clients have a modified diet. The food is properly stored in the refrigerator.

Client Records - Incident Reports: LPA reviewed four (4) client files which included Face Sheet, Identification and Emergency Information, Admission Agreement, Physician’s Report, Ambulatory Status, TB Clearance, IPP (Individual Program Plan), and Client Rights. LPA reviewed Clients’ P & I.

Health-Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for four (4) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. LPA observed the First Aid Kit that had all required items.

Incidental Medical Services: Per Administrator, there is one (1) client that has a restricted health condition plan in file.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
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