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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591995
Report Date: 06/13/2023
Date Signed: 06/14/2023 09:27:45 AM

Document Has Been Signed on 06/14/2023 09:27 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:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosario Garcia TIME COMPLETED:
05:05 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 toured the facility inside and out, reviewed food supply, reviewed resident files, staff files, and reviewed resident medications.

Kitchen has a sufficient amount of perishable and non perishable food supply. 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 106.3 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. Fire drill was conducted on 6/1/23.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies cited on attached 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: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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 06/14/2023 09:27 AM - It Cannot Be Edited


Created By: Angelica Rea On 06/13/2023 at 04:34 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: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. LPA observed that the carpet througout the facility was not clean, and was in disrepair. LPA also observed that 4 out of 4 dining room chairs were not clean and are in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
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Administrator stated that the the carpeting will be replaced with new flooring, and the dining room chairs will be replaced. Administrator will send LPA photos of the corrections by POC due date.
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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
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