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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603021
Report Date: 08/31/2026
Date Signed: 08/31/2026 06:21:59 PM

Document Has Been Signed on 08/31/2026 06:21 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:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR/
DIRECTOR:		SHELLY YAMASHIROFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
08/31/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Medalyn Bandojo, Caregiver TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management/Health and Safety Check visit for the purpose of confirming that the facility is operating in accordance with licensing requirements.

During the facility tour, LPA observed six (6) residents and two (2) caregivers present. Residents were observed eating an early lunch and appeared appropriately groomed. Due to cognitive limitations, residents were unable to answer LPA's questions during the visit. LPA observed cleaning supplies accessible to residents in bathroom drawers and in the backyard. LPA also observed that the facility did not have a sufficient two-day supply of perishable food available for the residents. Deficiencies will be issued as a result of the observations. During staff interviews, two (2) of three (3) staff reported that the facility administrator of record has not been present at the facility for the past few months. One (1) staff reported that it had been approximately one month since the administrator was last present at the facility.

Exit interview was conducted with Medalyn Bandajo, Caregiver. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.
David Sicairos
Gabriela Castro
DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2026
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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Document Has Been Signed on 08/31/2026 06:22 PM - It Cannot Be Edited


Created By: Gabriela Castro On 08/31/2026 at 12:34 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2026
Section Cited
CCR
87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met by evidence by:
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Licensee shall ensure all cleaning chemicals are stored in locked areas and inaccessible to residents at all times. Licensee shall submit proof of correction and a written plan detailing how the facility will ensure cleaning chemicals will remain secured and inaccessible to residents at all times. Proof of correction and the written plan shall be submitted by the POC due date.
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Here’s a polished deficiency statement:
Based on observation during the facility walkthrough, LPA observed cleaning chemicals accessible to residents in the resident restroom cabinet, hallway restroom, and backyard which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/07/2026
Section Cited
CCR87555(b)(26)

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(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 by evidence by:
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Licensee shall ensure the facility maintains a sufficient supply of perishable food for a minimum of two (2) days at all times. Licensee shall submit proof of purchase, including receipts and photographs of the food supply by the POC due date.
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Based on observation during the facility walkthrough, the licensee did not comply with the section cited above, as the facility did not have a sufficient two-day supply of perishable food available for residents which poses/posed a potential health and safety or personal rights to residents in care.
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2026 06:22 PM - It Cannot Be Edited


Created By: Gabriela Castro On 08/31/2026 at 12:47 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
CCR
87405(a)

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(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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Licensee shall ensure that a qualified administrator is present at the facility for a sufficient number of hours to effectively manage and oversee the day-to-day operations of the facility, as required. Licensee shall submit a written plan detailing how adequate administrator coverage will be maintained, including the administrator's proposed schedule and hours of presence at the facility. The written plan shall be submitted to CCL by the POC due date.
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This requirement is not met as evidenced by:Based on staff interviews, two (2) of three (3) staff reported that the facility administrator of record has not been present at the facility for the past few months. One (1) staff reported that it had been approximately one month since the administrator of record was last present at the facility which poses/posed a potential threat to the health and safety or personal right to residents in care.
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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