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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603885
Report Date: 09/04/2026
Date Signed: 09/04/2026 04:34:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2026 04:34 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:DIGNITY FIRST ASSISTED LIVING FACILITYFACILITY NUMBER:
198603885
ADMINISTRATOR/
DIRECTOR:		HALLADJIAN,PAULINEFACILITY TYPE:
740
ADDRESS:1016 EAST LEADORA AVETELEPHONE:
(626) 376-6144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 3DATE:
09/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Pauline Halladjian, Administrator and Kevork Halladjian, Licensee TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPAs were greeted by Kevork Halladjian, Licensee and explained the purpose of the visit.

The facility is licensed to serve six (6) non-ambulatory residents, ages 60 and over. One (1) resident may be bedridden in Bedroom #3. The facility has an approved hospice waiver for six (6) residents.

At the time of the visit, there were two residents under hospice care.

FACILITY TOUR AND OBSERVATIONS:

During the facility tour, LPA observed Personal Rights postings displayed in a common area and accessible to residents. Residents had access to personal space, privacy, and adequate storage for their belongings. No firearms or other weapons were observed on the premises.

Physical Plant

The facility is a two-story home located in a residential neighborhood. The home consists of three (3) bedrooms, two (2) bathrooms, one (1) half-bathroom for staff located near the dining area, a kitchen, two (2) living rooms, dining area, laundry area, backyard with a swimming pool and pool house, and an attached garage. The laundry room area contains stairs that lead to the second-floor caregiver corridor. The second floor is inaccessible to residents and is designated for caregiver/staff use. The facility also has an additional attached room/bedroom that is currently utilized as an office. This room has a separate exterior entrance and is not accessible from the interior resident living area. (continued on 809C)

David Sicairos
Gabriela Castro
DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2026
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.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885
VISIT DATE: 09/04/2026
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 The backyard contains a swimming pool enclosed by fencing that was observed to meet regulatory requirements. The front and backyard areas contained shaded seating available for resident use. Passageways and exits were observed to be clear and unobstructed. Smoke and carbon monoxide combination detectors were observed, tested, and found to be operational. A fire extinguisher located in the dining area was observed to be charged. Appliances, including the microwave, refrigerator, and stove, were observed to be clean and operating properly. Sharps and chemicals were observed to be secured and inaccessible to residents. Water temperature was measured and observed to be within the regulatory range of 105°F to 120°F. Extra linens and towels were available and stored in a hallway closet. Smoke and carbon monoxide detectors were tested and found operational. LPA observed that the door alarms on the exit door in bedroom three (3) and areas of the home that were functioning.

Food Service

Refrigerators and freezers were maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and contained a sufficient supply of food, including at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were stocked.

Health-Related Services & Records

Three (3) resident files were reviewed. Files contained required documentation, including Admission Agreements, signed consents, Needs and Services Plans, Physician’s Reports documenting ambulatory status, and Resident Rights acknowledgments. However, all three (3) resident files reviewed did not contain documentation of proof of tuberculosis (TB) clearance. Three (3) residents’ medications were also reviewed. Medications were observed to be centrally stored and secured in a locked kitchen cabinet. During the medication review, LPA observed discrepancies between the Medication Administration Records (MARs) and the medications reviewed. Specifically, R1’s MAR was not maintained accurately, as it did not document whether R1 received or did not take the prescribed evening medications.Deficiencies regarding the missing TB documentation and inaccurate medication records will be cited.

Disaster Preparedness

Last fire/earthquake drill was conducted on August8, 2026.. LIC 610D Emergency Disaster Plan was observed to be updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed.

(continued on 809C)

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

DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885
VISIT DATE: 09/04/2026
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Personnel Records & Training

Three (3) staff files were reviewed and contained documentation of criminal record clearances, CPR/First Aid certification, and TB clearance. However, LPA did not observe documentation of required staff training for S2 and S3. A deficiency will be cited.

An exit interview was conducted with Pauline Halladjian, Administrator and Kevork Halladjian, Licensee. 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: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2026 04:34 PM - It Cannot Be Edited


Created By: Gabriela Castro On 09/04/2026 at 02:20 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: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met by evidence by:
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Administrator shall conduct a review of all residents’ MARs to ensure that medication administration, refusals, and medications not administered are properly documented. Administrator shall provide medication documentation training to all staff responsible for assisting residents with medications.
Proof of correction shall include a written statement confirming completion of the MAR review, copies of corrected/current MARs, and documentation of staff training, including training date, topics covered, and staff signatures, submitted to LPA by the POC due date.
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During the medication review, the facility was unable to provide a Medication Administration Record (MAR) documenting whether R1’s prescribed evening medications were administered or not administered which poses/posed an immediate health and safety, personal rights to residents in care.
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Type B
09/25/2026
Section Cited
CCR87458(c)(1))A)

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(c) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating the licensed medical professional's diagnosis...(A) Communicable tuberculosis.
During the resident record review, LPA observed that three (3) out of three (3) resident files reviewed did not contain documentation of tuberculosis (TB) clearance which poses/posed a potential threat to the health and safety, personal right to residents in care.
This requirement is not met by evidence by:
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Administrator shall obtain and maintain documentation of TB clearance for R1, R2, and R3. Administrator shall also review all resident files to ensure required TB documentation is complete and maintained in each resident’s record. Proof of correction shall be submitted to LPA by the POC due date.
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During the resident record review, LPA observed that three (3) out of three (3) resident files reviewed did not contain documentation of tuberculosis (TB) clearance which poses/posed a potential threat to the health and safety, 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: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2026 04:34 PM - It Cannot Be Edited


Created By: Gabriela Castro On 09/04/2026 at 02:26 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: DIGNITY FIRST ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87412(c)

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(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement is not met by evidence by:
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Administrator shall ensure that S2 and S3 complete all required training and that documentation of completed training is maintained in their personnel files. Administrator shall review all staff files to ensure required training is current and properly documented. Proof of training shall be submitted to LPA by the POC due date.
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During the staff record review, LPA did not observe documentation of required staff training for S2 and S3 which poses/posed a potential threat to the health and safety, 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: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2026


LIC809 (FAS) - (06/04)
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