<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603683
Report Date: 09/29/2026
Date Signed: 09/29/2026 01:45:45 PM

Document Has Been Signed on 09/29/2026 01:45 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:HOUSE OF GRACE 4 INC.FACILITY NUMBER:
198603683
ADMINISTRATOR/
DIRECTOR:		AGUIRRE, MICHELLEFACILITY TYPE:
740
ADDRESS:851 ENTRADA WAYTELEPHONE:
(626) 716-1033
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
09/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Aries Mendoza, Caregiver TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff. Administrator Michelle Aguirre was contacted via telephone and informed of the purpose of the visit.

The facility’s fire clearance is approved for six (6) non-ambulatory residents, ages 60 and over. The facility also maintains a hospice waiver for four (4) residents. At the time of the inspection, five (5) residents were receiving hospice care, which exceeded the facility’s approved hospice waiver capacity.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Long-Term Care Ombudsman information), Complaint Poster (PUB 475), and the nondiscrimination notice were observed posted in a common area. Residents had access to personal space, privacy, and adequate storage for personal belongings. No firearms or weapons were present at the facility.

Physical Plant:

The facility is in a residential neighborhood and consists of a single-story home with three (3) resident bedrooms, one (1) caregiver bedroom, and three (3) bathrooms, including one (1) caregiver bathroom and one (1) private resident bathroom. The facility also consists of a living room, family room/dining room, kitchen/dining area, detached garage, front yard, and backyard. At the time of the inspection, the detached garage was undergoing construction, and water piping was undergoing repairs. LPA did not observe any interruption or concerns regarding the availability of water for residents in care. Resident bedrooms observed contained the required furnishings, including beds, mattresses, linens, dressers, chairs, and adequate lighting. During the walkthrough, LPA observed three (3) beds in Resident Bedroom #3. Facility staff reported that one (1) of the beds was scheduled to be removed on the day of the visit. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a secured kitchen cabinet. (continued on 809C)

David Sicairos
Gabriela Castro
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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)
Page: 2 of 8
Document Has Been Signed on 09/29/2026 01:45 PM - It Cannot Be Edited


Created By: Gabriela Castro On 09/29/2026 at 01:20 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: HOUSE OF GRACE 4 INC.
FACILITY NUMBER: 198603683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation during the facility walkthrough, the licensee did not comply with the section cited above. LPA confirmed that five (5) residents were receiving hospice care; however, the facility’s current hospice waiver is approved for a maximum of four (4) residents. The facility exceeded its approved hospice waiver capacity by one (1) resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
1
2
3
4
Administrator will submit a written request to Licensing for an increase to the facility’s current hospice waiver to accommodate the number of residents receiving hospice care by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
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: HOUSE OF GRACE 4 INC.
FACILITY NUMBER: 198603683
VISIT DATE: 09/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Cleaning supplies were secured in the laundry room and in a secured cabinet underneath the kitchen sink. Bathrooms were observed to be clean and equipped with required safety features, including grab bars near toilets and bathing areas and non-skid mats. Toilets, sinks, and bathing fixtures were observed to be operational. Hot water temperature was observed outside the required regulatory range of 105°F–120°F. Extra linens and towels were available and stored in the hallway. Smoke and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were observed and available. No bodies of water were present on the premises. Passageways and exits were observed to be clear and unobstructed. The front and backyard areas contained shaded seating areas available for residents’ use.

Food Service:

Refrigerators and freezers were maintained at appropriate temperatures, with refrigerators observed at or below 40°F and freezers at 0°F. The facility maintained a sufficient supply of at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were observed and available for resident use.

Health-Related Services & Records:

Three (3) resident files (R1–R3) were reviewed. Resident files contained required documentation, including Admission Agreements, signed consents, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments. During record review, LPA observed that the Needs and Services Plans for R1–R3 had not been updated. An advisory note will be provided as a reminder of the requirement to ensure residents’ Needs and Services Plans are reviewed and updated as required.

Three (3) residents’ medications and medication records were reviewed. Medications were observed to be centrally stored and secured in a locked medication storage area located in the laundry room.

Disaster Preparedness

The most recent fire/earthquake drill was conducted in January 2026. LPA reminded facility staff of the requirement to conduct emergency disaster drills at least quarterly and to maintain documentation of the drills. The LIC 610D Emergency Disaster Plan was available for review and was in the process of being updated at the time of the inspection. Emergency supplies, including water, food, flashlights, batteries, and first aid supplies, were observed and available for use in the event of an emergency.


Personnel Records & Training

Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Michelle Aguirre was found to be current.

An exit interview was conducted with Aries Mendoza, 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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
Page: 8 of 8