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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 06/25/2026
Date Signed: 06/25/2026 05:39:03 PM

Document Has Been Signed on 06/25/2026 05:39 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR/
DIRECTOR:		BELEN TAICOFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 4DATE:
06/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Crystal Garcia, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff. Administrator Belen Taico was explained the purpose of the visit telephonically.

The following was observed during the inspection:

Infection Control: The facility has an Infection Control Plan that is reviewed annually.

Operational Requirements: A Dementia and hospice waiver for 4 residents has been approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expires 8/26/2026.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is located in a residential neighborhood that consists of 4 resident rooms, 2 bathrooms, dining room/ living room, office, laundry room, medication/storage room, outdoor patio area, and detached garage. Smoke and carbon monoxide detectors were tested and are operational. The facility has three (3) fire extinguishers. Rooms are equipped with required furniture and bedding. Cleaning supplies and toxic substances are inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Electrical smoke and carbon monoxide detectors were tested and are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. First aid kits/Manuals are kept in activity rooms; consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. Exit doors are free of any obstruction. The last Emergency Disaster drill was conducted on 6/18/2026.

* R1 & R2's bed had full length bed rails but residents are not enrolled in hospice. Room #4 has an oxygen tank, but required No Smoking posting was not observed.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2026
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HENRIETTA'S HOME
FACILITY NUMBER: 198603585
VISIT DATE: 06/25/2026
NARRATIVE
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Staffing: A total 6 staff members provide care and supervision to the residents.

Personnel Records/Staff Training: Five files were reviewed. Files were reviewed for criminal background clearance, training, health clearance, and 1st Aid/CPR training. Staff (S4) is not associated to the facility. Staff S3 & S4 do not have health screening. Staff (S3) does not have a 1st Aid/CPR training. Administrator did not provide documentation during the visit.

Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. One resident has a modified diet.

Incident Medical and Dental: Centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. Resident (R1's) Centrally Stored Medication And Destruction Record is not current. Four medications were not listed. *NOTE: The facility does not use MAR's.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Zero residents are enrolled hospice services and three (3) residents receive home health services.

Pursuant to Title 22, deficiencies were cited.


An exit interview was conducted with Crystal Garcia. A copy of the report/appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/25/2026 05:39 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/25/2026 at 05:00 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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that R1’s Triamcinolone .1% cream, Nystop 100,000, Nystatin 100,000, and Calamine Lotion are not documented on the Centrally Stored Medication and Destruction Record and does not use Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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Submit a copy by tomorrow of R1's updated Centrally Stored Medication and Destruction Record.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because R1 & R2's beds had full length bed rails and neither resident is currently enrolled in hospice services, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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Administrator shall ensure the full-size bed rails are removed from R1 & R2’s beds. Please submit a copy of the half size bed rails physician order along with a picture by tomorrow.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 05:39 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/25/2026 at 05:00 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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that an oxygen tank was observed in room #4 (R2 & R5'd) bedroom, but there was no "No Smoking-Oxygen in Use" posted sign in appropriate areas or in the facility physical plant, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
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Administrator shall ensure that a No Smoking-Oxygen in Use sign is posted when there is an oxygen tank(s) in the facility. Submit picture proof that the signs are posted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/25/2026 05:39 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/25/2026 at 05:12 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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in that staff (S4) is not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
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Submit proof by tomorrow that S4 was associated to the facility via Guardian.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 R1’s Triamcinolone .1% cream, Nystop 100,000, Nystatin 100,000, and Calamine Lotion are not documented on the Centrally Stored Medication and Destruction Record and does not use Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2026
Plan of Correction
1
2
3
4
Submit a copy by tomorrow of R1's updated Centrally Stored Medication and Destruction Record.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/25/2026 05:39 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/25/2026 at 05:12 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: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that Staff (S3 & S4's) health screening was not in their file or presented during the visit. Administrator did not provide documentation during the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Submit copies of S3 & S4s health screening and TB exam clearance.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that staff (S3's) file did not have proof that 1st aid/CPR training has been completed. Administrator did not provide documentation during the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2026
Plan of Correction
1
2
3
4
Submit a copy of S3’s 1st Aid/CPR training card.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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