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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003757
Report Date: 12/05/2025
Date Signed: 12/05/2025 11:38:45 AM

Document Has Been Signed on 12/05/2025 11:38 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:MILLS CARE HOMEFACILITY NUMBER:
306003757
ADMINISTRATOR/
DIRECTOR:		RAFAEL TORRESFACILITY TYPE:
735
ADDRESS:9737 MILLS AVENUETELEPHONE:
(562) 945-6416
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 3DATE:
12/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jackie Mikin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced, required annual visit today. LPA was greeted by Edwin Teoco, Direct Support Professional, and the reason for the visit was explained. Administrator, Jackie Mikin, arrived thereafter and continued to facilitate the visit.

Facility is licensed to serve (4) developmentally disabled adults, ages 18-59, (2) ambulatory and (2) non-ambulatory. During today’s visit, the facility is not operating within the scope of its license due to having (3) non-ambulatory clients in care out of the (2) non-ambulatory permitted by the current license. Clients in care receive services from the Eastern Los Angeles Regional Center (ELARC). The facility is in a residential area of Whittier.

The single story-home consists of living room, kitchen, dining area, (3) client bedrooms, (1) staff room, (3) full bathrooms, laundry area, front and backyard, and detached garage.

Tour of the physical plant:

The facility was observed clean inside and out. Walkways, passageways, ramps and exits are free of debris and obstructions. The facility does not have pools or other bodies of water. Living and dining room furniture is in good repair, and enough seating is available for clients. Fireplace was observed covered and inaccessible to clients. Client bedrooms have the required furniture and bedding, and each room has ample closet space. The bathrooms are kept clean, and showers have safety grab bars and anti-slip mats. The water temperature was tested and measured within 105-120 degrees F. compliance range. Kitchen was observed clean, and appliances were operable. The facility has sufficient 2-day perishable and 7-day non-perishable food supply which 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: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2025
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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Document Has Been Signed on 12/05/2025 11:38 AM - It Cannot Be Edited


Created By: Mayra Cota On 12/05/2025 at 10:37 AM
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: MILLS CARE HOME
FACILITY NUMBER: 306003757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that (3) out of (3) clients are non-ambulatory but the facility is licensed to serve only (2) non-ambulatory clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2025
Plan of Correction
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Administrator will correct status on license and email LPA plant to correct.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2025


LIC809 (FAS) - (06/04)
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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: MILLS CARE HOME
FACILITY NUMBER: 306003757
VISIT DATE: 12/05/2025
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Carbon monoxide and Interconnected smoke detectors were tested and found to be working properly. The facility has (1) fire extinguisher which is kept charged. The fire extinguisher was last inspected on 3/26/35. The detached garage is kept locked and storage space is free of clutter. An overflow freezer is kept in the garage and was observed stocked. The backyard has shaded area, and the patio furniture is in good repair.

Record Review:

Three (3) client and (3) staff files were reviewed and found to have all mandated documents in place. Facility has an updated Emergency Disaster Plan. Safety drills are conducted quarterly, and the last drill was conducted on 9/6/25. Facility also has a current Surety Bond.

Medication review:

Medication review was conducted and found to be dispensed and documented accordingly.

During today’s visit, a deficiency was noted, and a citation was issued per Title 22 Regulations. Exit interview was conducted with Jackie Mikin, Administrator, and a copy of this report, LIC 809-D and Appeals Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC809 (FAS) - (06/04)
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