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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603657
Report Date: 09/03/2026
Date Signed: 09/03/2026 02:42:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 02:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOME 'R USFACILITY NUMBER:
198603657
ADMINISTRATOR/
DIRECTOR:		ISIDRO, MARGARITAFACILITY TYPE:
740
ADDRESS:10423 TRABUCO ST.TELEPHONE:
(562) 376-0298
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 3DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:02 PM
MET WITH:Margie Isidro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Margie Isidro and explained the purpose for today’s visit. The facility is licensed to serve 6 Ambulatory Adults Age 60 and over, (2 of which may be non-ambulatory in Room #1, 1 non-ambulatory in room #2, 2 non-ambulatory in room #3, and 1 ambulatory). There is a Hospice waiver for 2 residents.

The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: 4 bedrooms (2 of which are vacant), 2 full bath (1 full bath is inside room #1), 1 1/2 bath, living room, dining area, kitchen, attached garage with laundry, front yard and back yard. There is an ADU in the back yard that Administrator resides in, there are no residents living in ADU.

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


Infection Control: Facility maintains the required Infection Control Plan.
Operational Requirements: There's an approved fire clearance.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Residents with Special Health Needs: There currently are no residents on hospice at the facility.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/earthquake drill was conducted on 8/18/26. (Continued on LIC809-C)
David Sicairos
Tena Herrera
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOME 'R US
FACILITY NUMBER: 198603657
VISIT DATE: 09/03/2026
NARRATIVE
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Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. 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 throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Staffing: There are currently 2 staff for facility, Administrator stated since there are only 3 residents with little care needs there is no need for additional staff, LPA advised Administrator that additional staff may need to be hired if more residents are admitted to meet their needs.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 2 staff files with no issues observed. Administrator Margie Isidro has a valid certificate that was verified through the CCL website with an expiration date of 2/1/28.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 3 resident files and reminded Administrator to use the proper forms for the required yearly appraisal needs and service planIncidental Medical & Dental: Medication is centrally stored in a locked cabinet. LPA reviewed 3 residents’ medications and observed the following. LPA observed Resident #1 was missing 3 medications that are listed on the Medication list and there were other medications stored in basket that are not listed on medication list, for Resident #2 LPA observed 2 medications that are being administered but not on medication list provided for review. There were 2 medications in R1's private bath that were unlocked, per physician report cannot administer own medications. (citations will be issued and detailed on LIC809-D).

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on LIC809-D. Exit interview held and a copy of the report and appeal rights were provided to Margie Isidro.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:42 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/03/2026 at 02:12 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: HOME 'R US
FACILITY NUMBER: 198603657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (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 was not met as evidence by:
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Administrator/Licensee was reminded of this requirement and it was explained that moving forward all medication for residents that cannot administer their own medications must be centrally stored in a locked area. POC was cleared during visit
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During facility tour LPA observed 2 bottles of liquid medication in R1's private bath within their room, per physician report they are not able to administer their own medications.
(administrator removed medication from room and stored in the medication cabinet during visit)
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Type A
09/04/2026
Section Cited
CCR87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:
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Administrator/Licensee to obtain most up to date medication list for both residents and ensure that the facility has all medications on hand for proper medication administration. A copy of the updated medication list and proof of all medications being ordered or at facility shall be sent to LPA via email by POC due date.
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During medication review LPA observed the following medication missing for R1 (that is listed on medication list) Cefdinir (capsule) {Brang-Omnicef) 300mg, Diclofenac Sodium (gel) {Brand-Voltaren) 1%, Neomycin Polymyxin-HC (solution) 1% and the following medication missing for R2 that is being administered but not on med list Senna 8.6mg tablet, Olmesartan Medoxomil 40 mg tablet which poses an immediate threat to the health and safety of 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:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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