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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603921
Report Date: 09/17/2026
Date Signed: 09/17/2026 01:06:34 PM

Document Has Been Signed on 09/17/2026 01:06 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:ELDERHART, INCFACILITY NUMBER:
198603921
ADMINISTRATOR/
DIRECTOR:		SEIDFATHI, HANNAFACILITY TYPE:
740
ADDRESS:1625 BANCROFT WAYTELEPHONE:
(818) 554-5047
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
09/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Hanna Seidfathi - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Jay Catacutan and Daniela Cortez, Caregivers and explained the purpose of the visit. The administrator, Hanna Seidfathi was called on the phone and arrived shortly thereafter to assist LPA. The facility is licensed to serve adults ages 60 and over. Approved for six (6) non-ambulatory residents of which one (1) may be bedridden in bedroom #1. Waiver/granted for hospice care for six (6). There are (4) residents residing in the home, but (1) resident is currently hospitalized. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The facility is a single-story home located in a residential area consisted of four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room with covered fireplace, laundry area, attached garage, and a backyard with seating and shade. Front entry and all exits have a wheelchair ramp. The facility has an updated Infection Control Plan in place. Staff are adhering to infection control requirements. The facility has a valid Liability Insurance policy, expires on 11/10/2026. The facility does not handle residents' cash resources. Fire Drill is conducted on a quarterly basis, last drill was conducted on 09/05/2026. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, overhead lighting, chair and sufficient closet space. Beds and furnishings are in good working condition. Bathrooms were clean and contained a working toilet, basin, and water faucet, shower with non-skid mats. One (1) fully charged fire extinguisher was observed, purchased on 07/17/2026. Attached garage was inspected and there are extra refrigerator and freezer stocked with additional food items. Cleaning supplies are stored in the cabinet at the garage and inaccessible to residents. Kitchen knives, sharps objects, are kept locked in a kitchen cabinet. Smoke alarm/carbon monoxide combo was tested and operable. There are cameras without audio inside (common areas only) and outside of the facility. Backyard was inspected and has a shaded area and sitting area. No bodies of water were observed. LPA observed (2) buckets of left over paint and a wood pile in the side yard that need to be cleared out. Hot water was tested in bathroom #1 and measured at 112.6 deg F which was within normal limits 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit. ***CONTINUED ON LIC809-C***
Lisa Hicks
Bennette Pena
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELDERHART, INC
FACILITY NUMBER: 198603921
VISIT DATE: 09/17/2026
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There are (7) staff including the night shift and administrator providing care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. LPA reviewed (4) staff files that include: personnel record, staff training, health clearance, employee rights, and 1st Aid/CPR/AED training. Administrator certificate is valid and expires on 06/11/2027. Resident personal rights are posted. Facility provides internet service to all residents and have access to the facility phone. The indoor activity area is appropriately furnished and comfortable for residents' relaxation. Outdoor activity areas have adequate shady areas. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. There are (0) residents with modified or restricted diets. Emergency water supply was observed. All the appliances are working and in good condition. Cleaning supplies and toxins are locked only accessible to staff. LPA reviewed (4) resident files which include Face Sheet, Physician's Report (including TB and Ambulatory Status), Admission Agreement, Appraisal Needs Services plan and Residents Rights observed. LPA observed that (1) of (4) residents did not have a physician's order for half bed rail on file. The medications are centrally stored and in their original containers. All (4) residents' medications were reviewed to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document that medications are given according to Physician directions. There are no residents with restricted health conditions. The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites.

No deficiencies cited. Technical advisories issued.

Exit interview was conducted and a copy of this report was provided to Hanna Seidfathi.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
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