Illustration — no photo of this home on file yet

Villa Victoria

Small home·Licensed for 6·Glendora, California

Licensed since 2021Licence #198603439
(626) 888-7811From the state roster · September 13, 2026Plan a visit
  • Care approvals on fileWheelchair · HospiceState licensing record · September 13, 2026
  • Estimated starting rate$4,800 a monthCovelight estimate · likely $3,900–$5,900
  • Home sizeLicensed for 6Small care home · a licensed care home (RCFE)
  • Room at the last state visit6 of 6 beds occupiedApril 18, 2024 · not a current opening
  • Ways to payAsk the homeMedi-Cal ALW participation not on file
  • Last state visitJune 30, 2026CDSS inspection record

Villa Victoria is a small care home in Glendora — a licensed residential care facility for the elderly (RCFE), the licence category behind “assisted living” and “board and care.” It is licensed for 6 residents since 2021. Dementia care and bedridden care are not on file.

Built from CDSS public records · September 13, 2026. Every fact below names its source and date.

Quick answers and the state record

A citation does not make a home unsafe, and an empty file does not make a home good.

Quick answers about Villa Victoria

Is Villa Victoria licensed?

The state lists this license as “Licensed,” per CDSS records as of September 13, 2026.

How many residents is Villa Victoria licensed for?

6 residents — a small home, per CDSS records as of September 13, 2026.

Has Villa Victoria been cited?

0 Type A and 3 Type B citations since 2021, per CDSS records as of September 13, 2026. Those records count 16 state visits over the same years.

Is Villa Victoria still open?

This license was on the CDSS roster as of September 28, 2026.

What does Villa Victoria cost?

$4,800 a month to start is a Covelight estimate, likely $3,900–$5,900. This home’s own rate is not on file. Ask: “What is the all-in monthly rate, and what would push it higher?”

Covelight’s estimate starts from the rates 22 small homes and similar homes within 10 miles publish, then adjusts for this home’s size, state care approvals, Medi-Cal waiver participation, years licensed and the area’s prices. In testing, the likely range held the real rate for 6 in 10 homes. This home’s own rate is not on file.

Among 228 other homes of a similar licensed size across Los Angeles County that publish a starting rate, the middle half runs $4,000 to $6,300 a month, and the middle figure is $5,000 (n = 228 other homes publishing a starting rate).

Each of those is a home’s own published figure, gathered on its own date in September 2026 — not an average of ours, and not a survey. Similar size means small and mid-size homes counted together, and large communities counted on their own, because they are different markets.

A home outside the band is not overcharging or underpricing: a starting rate covers different things in different homes, which is the first thing to ask about.

The price is made in the phone call. Nothing here is a quote, an offer or a discount.

A starting rate is the room and the base care. California homes commonly bill care levels, medication management, supplies, transport and a second person in the room as extras. Many also charge a one-time fee at move-in. Ask for that list in writing before anything is signed.

Only prices a home put out itself count here: its own website, a listing it supplied, or a price a listing site says the home confirmed. Prices a site shows without saying where they came from are left out.

Does Villa Victoria take Medi-Cal?

On Medi-Cal’s Assisted Living Waiver: this home is not on the DHCS participation list dated September 23, 2026. Ask the program about current options. The waiver pays for care services, not room and board.

Who holds the license?

The license is held by American Board and Care, LLC, per CDSS records as of September 13, 2026.

Is there a hospital nearby?

Emanate Health Foothill Presbyterian Hospital is 1.7 miles away in a straight line, per the CDPH licensed-hospital list dated September 16, 2026. See licensed care homes near it.

Can Villa Victoria keep a resident on hospice?

Hospice care is approved on this license, covering up to 5 residents, per CDSS records as of September 13, 2026.

Villa Victoria license and inspection record

  • Name on the license: “VILLA VICTORIA”, per the CDSS roster as of May 25, 2025.
  • License #198603439. The state lists this license as “Licensed,” per CDSS records as of September 13, 2026.
  • Licensed for 6 residents — a small home, per CDSS records as of September 13, 2026.
  • Licensed to American Board and Care, LLC, per CDSS records as of September 13, 2026.
  • First licensed in 2021, per CDSS records as of September 13, 2026.
  • 16 state inspection visits since 2021, per CDSS records as of September 13, 2026.
  • 0 Type A and 3 Type B citations on file since 2021, per CDSS records as of September 13, 2026. The same records count 16 state visits in that period.
  • 3 complaints and 3 substantiated allegations on file since 2021, per CDSS records as of September 13, 2026. One complaint can carry several allegations.
  • The most recent state visit on file is June 30, 2026, per CDSS records as of September 13, 2026.
Type A citationa violation that poses an immediate risk to health, safety or personal rights if it is not correctedType B citationa violation that could become a risk if not corrected, or one involving records, resources or required services

California writes these definitions for every licensed home, not for this one. CDSS citation definitions (PDF) ↗

See the state’s own record

Can they support the care needed?

California licenses a home for specific kinds of care. The state’s record lists what this home is approved for; the home’s own answers fill in what changes as needs change.

  • Wheelchair / non-ambulatoryApproved · covers up to 3 residents
  • Dementia / memory careNot on file · ask the home
  • Hospice careApproved · covers up to 5 residents
  • BedriddenNot on file · ask the home

State licensing record · September 13, 2026. An approval may cover specific rooms or residents; it does not establish an opening.

Read the state’s own wording
AGE RANGE 60 AND OVER. APPROVED FOR 3 AMBULATORY AND 3 NON-AMBULATORY. THE NON-AMBULATORY RESIDENTS WILL INCLUDE 2 RESIDENTS IN BEDROOM #1 AND 1 RESIDENT IN BEDROOM #5. HOSPICE WAIVER FOR 5.

935 - ELDERLY

CDSS record, verbatim · September 13, 2026

As needs change

  • Staying through hospice

    Hospice waiver on file · covers up to 5 — care may continue at the end of life

    Ask: “If hospice is needed, can care continue here until the end?”

    State licensing record · September 13, 2026

4 more questions to ask the home
  • Two-person transfers or a lift

    Not on file

    Ask: “If two people or a lift are needed to transfer, can the person stay?”

  • Someone awake overnight

    Not on file

    Ask: “Who is awake overnight, and how do residents ask for help?”

  • Medicines

    Not on file

    Ask: “Who manages the medicines, and what happens when a dose is missed?”

  • If memory loss develops

    Dementia-care designation not on file

    Ask: “If memory loss develops, what would change — and when would a move be needed?”

What it costs here

Covelight estimate

$4,800a month to start

Likely $3,900–$5,900

From 22 nearby homes that publish rates · this home’s rate is not on file

Likely monthly total

$4,800a month

Likely $3,900–$6,100

With a shared room and basic help.

An estimate for planning, not a quote. The price is made in the phone call.

See the full cost breakdownRoom, care and fees · how people pay · how this estimate works
Room
Daily care
Sharing the room

Memory care is not priced here: a dementia-care designation is not on file for this home. Ask the home.

  • Starting monthly rate$4,800likely $3,900–$5,900

    Covelight’s estimate starts from the rates 22 small homes and similar homes within 10 miles publish, then adjusts for this home’s size, state care approvals, Medi-Cal waiver participation, years licensed and the area’s prices. In testing, the likely range held the real rate for 6 in 10 homes. This home’s own rate is not on file.

  • Basic help with daily careUsually includedup to $600

    Basic help is usually part of the starting rate. Homes that price care by level start around $600 a month (45 California homes publish a care-level range, seen in September 2026).

  • One-time move-in fee$2,000one time · likely $0–$4,000

    Homes that list a one-time entry or community fee charge a median of $2,000 (134 California listings; middle half $1,000–$4,000). Many homes list none — ask.

Likely monthly totalLikely $3,900–$6,100
$4,800
First monthWith a one-time move-in fee · likely $4,600–$9,200
$6,800
How people payPrivate pay, Medi-Cal waiver, SSI/SSP, veterans, insurance
  • Private payMost residents pay from savings, a home sale or family help. Ask for the rate and what it includes in writing.
  • Medi-Cal Assisted Living WaiverThis home is not on the DHCS participation list dated September 23, 2026. Ask the program about current options. The waiver pays for care services, not room and board.
  • SSI/SSPCalifornia’s 2026 standard is $1,626.07 a month; $1,444.07 of it goes to the home and $182 stays with the resident. Whether this home accepts it is not on file — ask.
  • VeteransVA Aid & Attendance can add to a veteran’s or surviving spouse’s pension. Ask whether residents here have used it.
  • Long-term care insuranceMost policies pay for licensed care homes. Ask what paperwork the home provides for claims.
  • MedicareDoes not pay for room and board in a care home. It can still cover hospice or home-health visits inside one.
If the money runs out, what Medi-Cal covers
Avoid surprises on the billWhat changes the price, and what to ask
  • The care level

    Some homes charge one all-inclusive rate. Others add levels or points as needs grow. Ask how the level is set, who decides, and what the next level costs.

  • What is billed separately

    Medication management, incontinence supplies, transportation and a second person in the room are often extra. Ask for the list in writing.

  • Move-in costs

    A one-time community fee or deposit is common. Ask what it covers and whether any of it comes back if the stay is short.

  • Increases

    California requires at least 90 days’ written notice, with reasons, before a rate rises (Health & Safety Code §1569.655). A change in the resident’s care level is the section’s own exception and can be billed sooner.

  • What is the full monthly cost for the room and care we need, and what does it include?
  • What would the next care level cost, and who decides when it changes?
  • What is billed separately, and is there a one-time fee or deposit at move-in?
  • Is any private-pay period required before another payment program can begin?
How this estimate worksWithin 25% for 7 in 10 homes in testing

Covelight’s estimate starts from the rates 22 small homes and similar homes within 10 miles publish, then adjusts for this home’s size, state care approvals, Medi-Cal waiver participation, years licensed and the area’s prices. In testing, the likely range held the real rate for 6 in 10 homes. This home’s own rate is not on file.

22 homes like this within 10 miles publish starting rates mostly between $3,150–$6,550.

  • Only prices a home put out itself count: its own website, a listing it supplied, or a price Seniorly says the home confirmed. Prices a listing site shows without saying where they came from are left out.
  • Nearby homes are the nearest of the same size that publish a rate, widening from 3 to 40 miles until at least 8 do. The estimate starts from what they charge, then adjusts for this home’s size, state care approvals, Medi-Cal waiver participation, years licensed and the area’s prices.
  • Room, care-level, second-person and move-in lines come from what California homes publish on listing sites. Memory care uses Covelight’s researched premium over assisted living.
  • Totals add each line’s figure and combine the lines’ ranges as separate charges, because a home is rarely at the top, or the bottom, of every line at once.
  • We tested this estimate on 1,546 California homes that publish their own starting rate. It was within 10% of the real rate for 3 in 10 homes and within 25% for 7 in 10; the likely range held the real rate for 6 in 10 (September 12, 2026).
  • It cannot see this home’s specials, how it assesses care, or which rooms are open.
Show the 22 nearby homes behind this estimate

Where it is

  • 1640 S. Glendora Ave, Glendora, CA 91740Address from the public record · September 13, 2026. Confirm the entrance with the home before visiting.

Opening the neighborhood map…

The state record

California inspects every licensed home and publishes what it found. Here are the dated documents and the state’s own words, beside what is typical for homes this size.

Since 2022, the state has filed 14 documents for this home, and its records count 16 visits since 2021. The most recent is a facility evaluation report, dated June 30, 2026.

On file since
2022
State visits
16
Most recent visit
June 30, 2026
Occupied · April 18, 2024 visit
6 of 6 bedsa count on that day, not an opening

We hold 3 complaint reports the state published for this home, dated April 13, 2022 to April 18, 2024. 3 of the 3 carry the state's recorded outcome word: “Substantiated” (2), “Unsubstantiated” (1). 3 include the transcribed allegation the state investigated, word for word. Summary composed by computer from the 3 complaint reports below — every count derives from them, and the documents themselves are the state's records, verbatim. We never grade, score, or color a record.

Beside homes the same size

  • Type A citations0typical 0
  • Type B citations3typical 0
  • Substantiated allegations3typical 0
  • Total complaints3typical 0

“Typical” is the statewide median across the 6,808 licensed small board-and-care homes (6 or fewer beds) in the state record — larger, longer-licensed homes accumulate more visits and reports, so compare like with like. One complaint can contain several allegations. Counts cover this licence since 2021.

Year by year
YearVisitsDocumentsSubstantiated20261102025110202446120233312022230

The last 36 months — 8 of 14 documents

The full record on the state’s site →
20261 state visit · 1 document
Jun 30, 2026Facility evaluation reportReport on file

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff, and the purpose of visit was explained. Administrator Yenny Indrawati was notified and arrived shortly after. This facility is licensed to serve residents ages 60 and over, three (3) non-ambulatory and three (3) ambulatory. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. The facility has a hospice waiver for five (5). There are currently zero (0) residents receiving hospice services. The facility is operating within the scope of their license. The facility is a single-story home located in a residential area of Glendora. The home consists of living room, dining room, kitchen, 6 resident bedrooms, 3 bathrooms, laundry area and attached garage. The backyard has a newly constructed, vacant, ADU. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. continued on LIC 809C Combination smoke and carbon monoxide detectors were observed in the hallway, tested and are operable. All resident bedrooms contained required furniture, linens and lighting. Linens were clean and in good repair. LPA observed bedrails for 4 out of 5 residents but no physician orders for bedrails in place. Deficiency cited. Water temperatures in all grooming and bathing areas were measured below the required 105 – 120 degrees F. Licensee adjusted the water temperature at the time of visit. Technical advisory issued. LPA observed grab bars near toilets and showers and no-slip flooring and mats in the showers and bathtubs. LPA observed at least 2 days of perishables and 7 days of non- perishable food supplies. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. LPA observed live roach and insect activity in kitchen drawers, cabinets and dining room table. Deficiency cited. LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed a facility land line. The facility has the Emergency Disaster Plan (LIC610D) in place. Last earthquake and fire drill was conducted 05/01/26. LPA observed facility sketches with exits and emergency exits routes throughout various locations of the facility. No large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Medications are centrally stored in a locked kitchen cabinet. LPA observed pilled boxes with pills, labeled with days of the week and residents’ names. Deficiency cited. LPA observed boxes of insulin injections in the refrigerator door, not in a safe and locked making them accessible to persons other than employees. Deficiency cited. The facility uses the Medication Administration Record (MAR) log to document medications given. continued on LIC 809C page 3 Administrator Certificate for Yenny Indrawati and it expires 02/17/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. LPA reviewed two (2) staff files. Files were observed to contain required annual training, CPR and First Aid, Health screening, and fingerprint clearance for two (2) out of the two (2) personnel records reviewed. TB testing/clearance was not available for review for S1. Deficiency cited. Administrator did not have a file maintained at the facility available for review. Deficiency cited. LPA reviewed administrator’s documents via cell phone. Facility has an Infection Control Plan in place. LPA reviewed resident files for five (5) residents. Resident files are maintained at the facility. 5 out 5 resident files contained admission agreement, resident rights, medical assessment with TB clearance and pre-appraisals. 1 out of 5 files reviewed did not contain a reappraisal which should be updated in writing as frequently as necessary or once every 12 months. Deficiency cited. 5 out 5 files reviewed did not contain functional capabilities. Deficiency cited. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report, LIC809D and appeal rights were provided to Caregiver Luz Macalisang.the state’s words, verbatim · CDSS document, Jun 30, 2026

The state marks this report as 10 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

20251 state visit · 1 document
Jul 29, 2025Facility evaluation reportReport on file

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced required annual inspection. LPA met with Caregiver Luz Macalisang and explained the purpose of today’s visit. Administrator Yenny Indrawati was notified and arrived shortly after. This facility is licensed to serve three (3) non-ambulatory and three (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. Facility may retain no more than five (5) hospice residents. There are two (2) residents receiving assisted care. The facility is a single-story dwelling located in a residential neighborhood. LPA utilized the CARE tools for the visit today and observed the following: Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof of liability insurance, and will email copy to LPA. The 1-story facility consist of the following: 5 Resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, and backyard area. Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons were observed to be inaccessible to residents. Carbon monoxide detectors and smoke alarms in hallways operational. LPA inspected two (2) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in bathrooms were measured within 105 – 120 degrees F., observed grab bars near toilets. Nonskid mats and shower chair were observed. Sharps and knives are inaccessible to residents. Laundry machine working properly. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Fire extinguisher is fully charged. Continued on 809C.......... Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff is participating in continuous trainings. CPR and 1st aid. Personnel Records Training: Staff files are maintained at the facility. LPA observed required annual training, CPR and First Aid for two staff personnel records reviewed. Observed TB testing, Health screening, fingerprint clearance for two (2) out of the two (2) personnel records reviewed. Food Service: LPA Vaid observe sufficient supply of nonperishable for one week and perishables for 2 days. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MARs) log to document medications given. The facility provides incidental medical services. Resident Records/Incident Reports: LPA reviewed two (2)resident files, files are maintained at the facility. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. LPA Vaid observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Emergency drills(fire and earthquake) were last conducted 7/19/25. Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed a facility land line. Residents with Special Needs: Staff does not use manual restrictive devices. No Deficiencies were observed on todays' visit. Copy of report given to Administrator Yenny Indrawati. Licensee will forward to case carry LPA Gonzalez pertinent documents regarding the ADU addition to the facility. Updated LIC 200, physical plant sketch. From city of Glendora: Occupancy class code, permits and pertinent documents received from city of Glendora planning department.the state’s words, verbatim · CDSS document, Jul 29, 2025
20244 state visits · 6 documents
Sep 4, 2024Facility evaluation reportReport on file

Type of visit: POC

This is a corrected version of previously dated report 7/23/2024. Verbiage was corrected to reflect the correct civil penalty dollar amounts.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction (POC) visit to clear deficiencies issued on 7/19/2024 during required annual inspection. LPA Ramirez was greeted by Caregiver Veilma Malitado and explained the purpose of the visit. The following deficiencies were observed and documented on 7/19/2024 and had a POC date of 7/22/2024: 1. Type A- 87202(a)(1)- FIRE CLEARANCE *immediate $500 civil penalty was assessed 7/19/2024. 2. Type A- 87555(b)(26)- GENERAL FOOD SERVICE REQUIREMENT * $250 for repeat violation in 12-month period was assessed on 7/19/2024. 3. Type A- 87465(h)(2)- INCIDENTAL MEDICAL AND DENTAL CARE SERVICES * $250 for repeat violation in 12-month period was assessed on 7/19/2024. Licensee did not send POC for violation 87202(a)(1) by 7/22/2024. The licensee sent LPA a copy of a request to increase the number of non-ambulatory residents at the facility. The licensee did apply for this in August of 2023; however, the licensee was not approved by this licensing agency or fire department to operate beyond the facility approved fire clearance. Therefore, LPA Ramirez will issue daily civil penalties for failure to correct violation of 87202(a)(1) from 7/23/2024 through 7/23/2024, in the amount of $100. Although the licensee did purchase additional nonperishables for six (6) residents for a minimum of 1 week, the licensee did not clear POC by sending proof of retraining of staff on this regulation by POC due date of 7/22/2024.Therefore, LPA Ramirez will issue daily civil penalties for failure to correct violation of 87555(b)(26) from 7/23/2024 through 7/23/2024, in the amount of $100. Licensee did secure medication that must be refrigerated in lock box; however, licensee did not send proof that staff received retraining by 7/22/2024. Therefore, LPA Ramirez will issue daily civil penalties for failure to correct violation of 87465(h)(2) from 7/23/2024 through 7/23/2024, in the amount of $100. Total amount of civil penalties issued today $300. Exit interview conducted via telephone with Administrator Yenny Indrawati, A copy of this report, 809-D, LIC 421IM, LIC 421FC and appeals rights was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024
Sep 4, 2024Facility evaluation reportReport on file

Type of visit: Office

An Informal Conference was conducted today in the Monterey Park Regional Office. The purpose of this informal conference meeting is to discuss the high number of citations that were issued during the annual inspection dated July 19, 2024 . Present in the meeting is Licensing Program Manager David Sicairos, Licensing Program Analyst Kimberly Ramirez, Licensing Program Analyst Daniel Konishi along with facility representatives Yenny Indrawati, Administrator and Sugi Wong, Licensee. The informal conference process was explained during this meeting. Issues discussed during the meeting were: High number of deficiencies that were cited during the Annual Inspection on July 19, 2024. Total 11 citations which were seven (7) Type A and four (4) Type B citations were issued. POC Visit dated 07/23/2024 in which three (3) Type A citations were issued. The facility has stated they will do the following to achieve continued and substantial compliance: 1 Non-Ambulatory resident moved out, facility currently has 3 Non-Ambulatory residents which is within the approved facility Fire Clearance. Licensee/Administrator discussed citations with facility staff and will ensure to meet Title 22 Regulations moving forward. Facility will continue to work with the City in order to obtain required permit for Fire Clearance update. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies issued following the meeting. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Sep 4, 2024
Jul 23, 2024Facility evaluation reportReport on file

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction (POC) visit to clear deficiencies issued on 7/19/2024 during required annual inspection. LPA Ramirez was greeted by Caregiver Veilma Malitado and explained the purpose of the visit. The following deficiencies were observed and documented on 7/19/2024 and had a POC date of 7/22/2024: 1. Type A- 87202(a)(1)- FIRE CLEARANCE *immediate $500 civil penalty was assessed 7/19/2024. 2. Type A- 87555(b)(26)- GENERAL FOOD SERVICE REQUIREMENT * $250 for repeat violation in 12-month period was assessed on 7/19/2024. 3. Type A- 87465(h)(2)- INCIDENTAL MEDICAL AND DENTAL CARE SERVICES * $250 for repeat violation in 12-month period was assessed on 7/19/2024. Licensee did not send POC for violation 87202(a)(1) by 7/22/2024. The licensee sent LPA a copy of a request to increase the number of non-ambulatory residents at the facility. The licensee did apply for this in August of 2023; however, the licensee was not approved by this licensing agency or fire department to operate beyond the facility approved fire clearance. Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87202(a)(1) from 7/20/2024 through 7/22/2024, in the amount of $300. Although the licensee did purchase additional nonperishables for six (6) residents for a minimum of 1 week, the licensee did not clear POC by sending proof of retraining of staff on this regulation by POC due date of 7/22/2024.Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87555(b)(26) from 7/20/2024 through 7/22/2024, in the amount of $300. Licensee did secure medication that must be refrigerated in lock box; however, licensee did not send proof that staff received retraining by 7/22/2024. Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87465(h)(2) from 7/20/2024 through 7/22/2024, in the amount of $300. Total amount of civil penalties issued today $900. Exit interview conducted via telephone with Administrator Yenny Indrawati, A copy of this report, 809-D, LIC 421IM, LIC 421FC and appeals rights was provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1 · Plan of correction due date: Jul 24, 2024

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement was not met as evidence by:the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee is operating beyond approved fire clearance. Licensee will contact Fire Department and notify regarding fire clearance, and apply and receive approvement of for fire clearance or obatin new medical assessment of residents in question. Licensee will provide LPA Ramirez with contact name, and phone number of fire personnel that was notified regarding fire clearance. Licensee must submit POC via email.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jul 24, 2024

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Licensee did supply nonperishables but did not send proof of retraining by 7/22/2024.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee will send proof of retraining on this regulation by 7/24/2024 via email.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jul 24, 2024

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Licensee secured medication in fridge but did not send retraining by 7/22/2024.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee will retrain staff on this regulation by 7/24/2024.

Jul 19, 2024Facility evaluation reportReport on file

Type of visit: Required - 1 Year

This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Caregiver Jermin Pattiradjawane and explained the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets. LPA Ramirez observed the following deficiencies: Smell of urine omitting from resident bedroom #5, blinds missing and broken in resident bedroom#5, resident bedroom#5 screens were observed to have dust debris all over the screen, broken and discarded fridge in backyard, bubbling, peeling and yellow-brown on ceiling in living room area, and facility dryer was observed to be in disrepair. LPA Ramirez will issue Type B deficiencies. SEE 809-C. Food Service: LPA Ramirez did not observe sufficient supply of nonperishable for one week. LPA Ramirez counted between 10 to 20 cans of canned food. Seven (7) out of the twenty (20) canned good had best by dates of 2020, 2021, 2022, and 2023. LPA Ramirez observed two (2) out of the twenty (20) canned good to contain best by dates of July 11, 2024. LPA Ramirez observed five (5) unopened bags of chips with guaranteed fresh until dates of Jan 2024 and May 2024. LPA Ramirez observed one (1) half full tub of animal cracker cookies with a best by date of May 2024. LPA Ramirez observed one (1) unopen can of cookies with a best by date of June 7, 2024. LPA Ramirez observed two (2) unopened bags of popcorn with guaranteed fresh dates of Feb 2024. LPA Ramirez did observe perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Freezer was observed to have dead insects suck to bottom of freezer floor. Refrigerator floor contained dead insects and hair strands. LPA Ramirez observed several bags of sandwich bread to smell rancid and could smell it through the bag. Some bags of bread were open and per staff interviews, residents were being served this bread. 2 insect eggs fell out of a bag of bread that was semi open when LPA inspected the bread. LPA Ramirez will issue Type A & Type B deficiencies based these on observation. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Present staff could not locate drills or recall drill being conducted in the last three months. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Resident#1 (R1) did not have a current medical assessment on file. LPA Ramirez will issue Type B deficiency based on observation. See 809-C. Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. LPA Ramirez observed two (2) residents’ medications in the facility refrigerator to be accessible. LPA Ramirez will issue Type A deficiency based on observation. Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. Four (4) out of the six (6) residents are nonambulatory. The facility may only retain 3 nonambulatory residents. LPA Ramirez will issue Type A and Type B deficiency and an immediate civil penalty based on these observations. Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents. Resident files are maintained at the facility. Eleven (11) deficiencies were cited today, six (6) civil penalty violations in the amount of $250 for each violation, for repeat offenses and one (1) immediate civil penalty for $500. Total amount of civil penalties and immediate civil penalties are $2,000. Exit interview was conducted and copy of this report, 809-D, LIC 421IM, LIC 421FC and appeals rights was provided.the state’s words, verbatim · CDSS document, Jul 19, 2024
Apr 18, 2024Complaint investigation reportSubstantiated

Allegation investigated: . Staff locked resident in bedroom.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with staff, Jermin Henny Patiradjawane. The purpose of the visit was explained. The investigation consisted of the following: LPA toured the facility, reviewed files, and interviewed staff and residents. The administrator was interviewed via telephone. 2 Staff (S1 – S2) and 5 Residents (R1 – R5) were interviewed at the facility. The investigation revealed the following: Allegation - Staff locked resident in bedroom. It is alleged that Resident #1's (R1) door could not be opened from inside. LPA interviewed the administrator and staff who denied locking the resident in the room. They stated the door was propped open all the time so resident could go in and out. (continue on next page) Substantiated The administrator stated that the resident had a key to unlock the door but lost it. Interviews with staff and witnesses revealed that R1 had tried to leave the facility unsupervised several times. LPA obtained a video footage of R1's previous door. It showed that the keyhole was placed inside of the room and was locked. R1 would need to use a key to unlock the door or someone from the outside would need to open the door. R1 would pound on the door because the door could not be opened from the inside. Staff would immediately open the door when R1 called out. Witnesses stated that while they were in R1's room and closed the door, they could not get out. Administrator and Staff acknowledged that the door knob was recently changed. Based on LPA observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the licensee via telephone. A copy of this report and appeal rights were given to the staff. 5 of the residents interviewed stated they use the heater when it is needed. When they ask the staff to turn it on, staff would assist. They stated the bedroom is at a comfortable temperature. 2. Allegation - Staff do not meet resident’s needs. It is alleged that the staff do not shower the resident. Staff interviewed stated they provide bed baths to residents daily. Staff stated Resident #1 (R1) does not want staff to shower and prefers to do it himself/herself. R1 is independent and can shower, dress, and use the toilet on own. LPA interviewed 5 residents. One of the residents stated he/she can do their own activities of daily living, while the other 4 stated that staff assist them with toileting and dressing when needed. Staff cleans them and provides bed baths daily. 3. Allegation - Resident's nutritional needs are not being met. It is alleged that facility does not serve nutritious food to residents. For example, the resident is served a hotdog and eggs for breakfast and sweets for dinner. LPA interviewed staff who indicated that they make the residents’ meals based on their preference. They ask the residents what they would like to eat and then make their food. None of the residents have a restricted diet but would cook food that are softer for consumption. They provide meat and vegetables in the meals. 4 out of the 5 residents interviewed stated the food is ok and are provided with different meats and vegetable. LPA observed a variety of meats, vegetables, and fruits in the refrigerator during the visit today. 4. Allegation - Facility failed to safeguard resident's belongings. It is alleged that Resident #1 (R1) lost a denture and a computer. The administrator stated that R1 did not have any items upon admission except for dentures. Staff acknowledged R1 wears dentures and were informed that R1 lost them recently. R1 could not recall if it was thrown away by mistake. One of the staff remembers seeing R1 with a computer but stated R1 has not used it since. Staff denied taking any of R1’s belongings. Staff stated R1 gets visitors often and do not know if the visitors took it with them. R1 had misplaced things in the past but was later found. The facility does not have a resident’s personal inventory safeguarding form for this individual. Based on the information gathered, there is insufficient evidence to prove that the facility is responsible in safeguarding the resident’s belongings. 5. Allegation – Facility is in disrepair. It is alleged that the t.v. is not working in R1’s room. LPA toured the facility and observed all the televisions working. R1 stated that the t.v works but is not sure how to use the controller. Staff indicated that the television was never broken and said that R1 has trouble using the remote. The other residents stated their t.v. works fine and have no issues with it. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the licensee via telephone. A copy of this report along with the appeal rights were given to the staff.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 28-AS-20240410124456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Apr 18, 2024

87468.1 Personal Rights of Residents in All Facilities (a) (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on observation and interviews, Resident #1's room could not be opened on the inside without a key which poses a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: The licensee shall ensure the residents can leave its room anytime. The lock shall be changed in Resident #1's room so that he/she can go in and out. **POC has been cleared as of today.***

Apr 18, 2024Facility evaluation reportReport on file

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit. The reason was explained to staff. During a complaint investigation today for #28-AS-20240410124456, LPA observed a resident who is using oxygen. LPA smelled cigarette smoke coming from inside the facility. Once bedroom #4's door was opened, the room was filled with cigarette smell. Staff accompanying LPA acknowledged that the resident often smokes inside the room while in bed. Staff also revealed that resident in bedroom #5 also smokes in the room and not outside. Staff interviewed stated the residents do not comply and smoke indoor. A deficiency was issued on the LIC809D. A copy of this report and appeal rights were given to the staff.the state’s words, verbatim · CDSS document, Apr 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(C) · Plan of correction due date: Apr 19, 2024

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611 (3) Ensuring that the use of oxygen equipment...(C) Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidenced by: Based on observation, the licensee did not ensure that residents are not smoking inside the facility which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: The licensee shall conduct a staff in-service training to ensure that residents are smoking only in designated areas. The POC is due 4/19/24.

What the state’s words mean
Substantiatedthe state found the allegation more likely true than notUnsubstantiatedthere was not enough evidence to prove a violation occurred — not a finding of wrongdoingUnfoundedthe evidence showed the allegation was false, could not have happened, or had no reasonable basisType A citationa violation that poses an immediate risk to health, safety or personal rights if it is not correctedType B citationa violation that could become a risk if not corrected, or one involving records, resources or required services

CDSS citation definitions (PDF) ↗ · CDSS complaint outcomes ↗

An “unsubstantiated” complaint is not a finding of wrongdoing — it means the state investigated and could not confirm the allegation. Outcome words are the state’s own; we never grade, score, or color a record, and we publish no reviews — the state’s dated documents and the questions below stand in their place.
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