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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591995
Report Date: 07/01/2022
Date Signed: 07/12/2022 09:37:56 AM

Document Has Been Signed on 07/12/2022 09:37 AM - 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:PTL GUEST HOMEFACILITY NUMBER:
191591995
ADMINISTRATOR:BELEN A.CONNOLYFACILITY TYPE:
735
ADDRESS:7112 HALRAY AVE.TELEPHONE:
(562) 698-1608
CITY:WHITTIERSTATE: CAZIP CODE:
90606
CAPACITY: 6CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rosario Garcia TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Caregiver, Rosario Garcia, who assisted with the visit.

LPA Rea discussed infection control practices with Ms. Garcia, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. The hot water temperature measured at 94.1 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operating. There is a carbon monoxide detector in the hallway, tested and operating.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies cited on attaced 809-D. Exit interview held and a copy of the report and appeal rights provided to Ms. Garcia
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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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Document Has Been Signed on 07/12/2022 09:37 AM - It Cannot Be Edited


Created By: Angelica Rea On 07/01/2022 at 01:06 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: PTL GUEST HOME
FACILITY NUMBER: 191591995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: LPA Rea observed that water temperature measured at 94.1 degrees F on today's visit.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 faucets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
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Licensee will ensure that the water temperature is corrected to measure between 105 Degrees F and 120 Degrees F by POC due date. Licensee will send LPA a temperature log for dates 7/2/22- 7/5/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
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