197606301-6-12-2026-28-AS-DKOI-DUYRSU-20260612131718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 06/12/2026
Date Signed: 06/12/2026 01:18:27 PM

Document Has Been Signed on 06/12/2026 01:18 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:	BROOKDALE MONROVIA		FACILITY NUMBER:	197606301
ADMINISTRATOR/ DIRECTOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	201 E FOOTHILL BLVD		TELEPHONE:	(626) 301-0204
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY: 75		CENSUS: 61	DATE:	06/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Ken Padilla, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:25 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) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by the Wellness Director, Ken Patrick Padilla, and explained the purpose of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over, hospice waiver approved for ten (10) residents and non-ambulatory to be housed on the second floor only.

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

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan in place.

Operational Requirements: A Fire Clearance is in place. Valid Liability Insurance is in place. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (10) is approved, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/09/2026. LPA reviewed that the Liability insurance is in place. Fire and disaster drills were last conducted on 05/11/2026.

Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room. Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room.
[Continue to LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

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 5

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 5

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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
	VISIT DATE: 06/12/2026

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

Physical Plant/Environment Safety [Cont.]: Third floor: (34) resident rooms and Laundry room. The interior and exterior physical plant was inspected. LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed Emergency Chairs at the stairways. Carbon Monoxide and Smoke detectors are interconnected and were tested annually and working properly. The living room had a covered fireplace that is inaccessible to residents. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#106, #109, #114, #134, 204, 218, 228, and 229) and the readings vary between 110.3 deg F to 131.5 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations.

Staffing: A total of (45) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records-Training: LPA reviewed six (6) staff files which include: Personnel Record/Job Application, health screening, TB test results, Employee Rights, valid First Aid/CPR/AED Training, Valid Food Handling Certificate, staff training. Executive Director’s Administrator’s certificate is valid and expires on 11/19/2027.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and they have access to the facility phone.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
	VISIT DATE: 06/12/2026

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

Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas.

Incident Medical and Dental: A total of five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. The first Aid kit was observed and has all required items.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that include the Face Sheet, Identification and Emergency Information form, Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Personal Service Assessment, Physician's Orders, Ambulatory Status, and Personal Rights.

Disaster Preparedness: Updated Emergency and Disaster Plan LIC 610E is in place with contact numbers and at least two (2) relocation sites. LPA observed the evacuation chairs at each stairway is in place.

Residents with Special Health Needs: Four (4) residents are receiving home health services. Two (2) residents receive hospice care. Three (3) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents’ doors.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview was conducted and an appeals rights and a copy of this report were provided to the Executive Director, Ken Patrick Padilla.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/12/2026 01:18 PM - It Cannot Be Edited

Created By: Daniel Konishi On 06/12/2026 at 01:08 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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA measured the water temperature readings in Room #s 106 (131.1 deg F), 109 (129.3 deg F), 134 (123.8 deg F), 218 (124.5 deg F) and 228 (131.5 deg F) which were not within the required 105 degrees F to 120 degrees Fahrenheit. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 06/13/2026
	Plan of Correction
1 2 3 4	Executive Director shall immediately adjust water temperature. Executive Director to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degrees F and 120 degrees F. Executive Director will provide a copy of the log to the department once water temperature falls within Title 22 guidelines..

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:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC809 (FAS) - (06/04)

Page: 5 of 5