<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592149
Report Date: 08/18/2021
Date Signed: 08/19/2021 10:04:19 AM

Document Has Been Signed on 08/19/2021 10:04 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:LOVING CARE GUEST HOMEFACILITY NUMBER:
191592149
ADMINISTRATOR:SABIO, MARILYNFACILITY TYPE:
735
ADDRESS:15027 - 15031 BLACKWOOD STTELEPHONE:
(626) 917-2312
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 12CENSUS: 9DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Aiona Grace Fortaleza TIME COMPLETED:
02:45 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) Christine Wong conducted an annual required visit. LPA met with caregiver Cynthia Remogat and explained the reason for the visit. Shortly After, the assistant manager Aiona Fortaleza arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted the mitigation plan and approved on 5/15/21.

The facility contains 2 Buildings. In Building 15027 there are 4 Client Bedrooms and 1 Staff Room and 1 client bathrooms. Building 15031 there are 3 Client Bedrooms and 1 Staff Room and 1 client bathroom and 1 staff bathroom, kitchen and dining area. Each client bedroom is no more than two clients per bedroom and they are all equipped with the proper furniture and linen; All the bathrooms are clean and operational. LPA tested the bathroom hot water temperature in the front house and back house are between 125.4 and 146.6 degrees F. which is beyond the required 105-120 degrees F. The All the appliances are clean and working properly. The common areas such as living room and dining are are clean and have the required furniture. One week supply of non perishables and 2 days perishable food were sufficient. LPA also tested the smoke detectors and carbon monoxides in the front house and back house and they are all interconnected and operable. All outdoor and indoor passageways were free of obstruction.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing, disinfecting products are available in each room and facility is disinfected every 2 hours, bathrooms have sufficient soap, paper towels, and signs, facility has an isolation room and a cart with PPE supplies, and PPE supplies are stored for 30 days.

The deficiency cited is documented on the attached 809D. A copy of the report and appeal rights will be provided to assistant manager.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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 2
Document Has Been Signed on 08/19/2021 10:04 AM - It Cannot Be Edited


Created By: Christine Wong On 08/18/2021 at 02:17 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: LOVING CARE GUEST HOME
FACILITY NUMBER: 191592149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021

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


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, LPA observed the hot water temperature in clients bathrooms in the front house and back house are tested beteween 124.5 and 145.6 degrees Fwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2021
Plan of Correction
1
2
3
4
The administrator will ensure the hot water temperature are between 105 and 120 Degrees F. The administrator will adjust the hot water temperature immediately and send the hot water log to LPA by 8/25/21
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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2