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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592149
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:16:29 PM

Document Has Been Signed on 07/18/2023 03:16 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
GREATER LA AC/SC, 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: 10DATE:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aiona Grace Gazil - Direct Support Professional ITIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Aiona Grace Gazil, Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Marilyn Sabio has been contacted by phone several times to no avail. The Administrator arrived at 2:26pm to assist LPA. The facility is licensed to care for Mentally Disabled Adults, ages 18 through 59, ambulatory only. Six (6) clients in 15027 only and six (6) clients in house 15031. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has no plan of operation or infection control plan in place. DSP Aiona stated that she will submit the current plan.Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: Proof of Surety Bond was unavailable at the facility and Administrator will submit a copy to CCL/LPA. Last Fire Drill was conducted on 5/11/2022.

Physical Plant/Environment Safety: The facility contains 2 Houses, House #1 is a structure located in the back (15027) consists of (4) clients bedrooms, (2) full bathrooms, kitchen area which is also utilized as a staff room, living room and a backyard. House #2 located in front (15031) consists of (3) bedrooms, (1) of which is being used as a staff room, 2 full bathrooms, living room, dining area, kitchen, laundry area, office area front porch, patio and detached garage. Currently, there are ten (10) clients living in the facility and all were out in the day program during the visit. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, and sufficient closet space. However the clients bedrooms were not equipped with night tables and reading lamps. Most of the bedrooms did not have trash cans. Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper, but did not have non-skid materials in the shower area. LPA observed that there are no window screens in some of the windows in both structures. LPA also observed cracked glass window in front of House #1 and was broken. Additionally, window sill/moldings are broken and chipped in bathroom #2 in House #2. Exit doors are free of obstruction and there are no pools or large bodies of water. Backyard was inspected and observed to be obstructed. LPA observed unused items like grocery carts filled with trash, used cans and bins outside house #2. Detached garage was inspected and LPA observed that the garage is in disarray. Chemicals and other hazardous materials were stored along with other furniture, beddings and food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are three (3) fire extinguishers observed to be expired and were last serviced on 2/28/2020. Smoke alarms and carbon monoxide were tested. (2) Smoke detectors in house #1 are broken and inoperable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 11:30am, hot water supply measured at 116.2 deg F in the kitchen sink, in House #1: 118.2 deg F in bathroom #1, 113.5 in bathroom #2, House #2: 117.4 deg F in bathroom #1 and 113.9 in bathroom #2.

*****CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LOVING CARE GUEST HOME
FACILITY NUMBER: 191592149
VISIT DATE: 07/18/2023
NARRATIVE
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Staffing: A total of three (3) staff members provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 4/28/2023.

Client Rights-Information: Client personal rights are posted. Per Aiona (DSP I), facility provides internet services to all clients and have access to the facility phone. (2) clients have personal cell phones and none of the clients have computers. Facility does not have a computer or tablet available for clients' use. LPA did not conduct client interviews during the visit as all (10) clients were out in the day program during the visit.



Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked in the cabinet in House #2). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: Medications stored in a kitchen cabinet was kept unlocked. The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Aiona Grace Gazil - Direct Support Professional I.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which (2) Smoke detectors in house #1 are broken and inoperable which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/19/2023
Plan of Correction
1
2
3
4
Administrator shall submit receipts and photos of the operable smoke and carbon monoxide detectors to CCL/LPA by POC due date.
Type A
Section Cited
CCR
80020(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which all (3) fire extinguishers at the facility had an expired service tag dated 2/28/2020. 2 of 3 fire extinguishers were mounted on the wall in the kitchen and the laundry area and 1 of 3 fire extinguishers was mounted on the hallway in House #1 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/19/2023
Plan of Correction
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3
4
The Administrator shall submit proof of service from fire department or replace the fire extinguishers and provide purchase receipts to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in that medications stored in a kitchen cabinet was kept unlocked which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/19/2023
Plan of Correction
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2
3
4
Administrator shall ensure that medication cabinet is locked at all times and inaccessible to clients. Administrator shall submit an in-service training conducted to the staff on duty regarding keeping medications safe and secure to CCL/LPA by POC due date.
Type A
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in that facility has not conducted any emergency drill since 5/11/2022 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 07/19/2023
Plan of Correction
1
2
3
4
Administrator shall ensure that emergency drills are conducted at least quarterly. Administrator shall submit a proof of the drill conducted to all the staff on duty to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which the facility has no plan of operation or infection control plan in place which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
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2
3
4
Administrator shall complete and submit a plan of operation to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(d)(1)
Infection Control Requirements
(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease.  (1) The Emergency Infection Control Plan shall include the applicable infection control measures required by the federal, state and local government public health authorities for the contagious disease, and shall be completed and sent to the Department within 15 calendar days from the date the state or federal emergency is proclaimed or declared. In the event there are differing standards between the government public health authorities, the licensee shall follow the strictest requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which the facility has no plan of operation or infection control plan in place which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall submit an emergency infection control plan to CCL/LPA by POC due date.

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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

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
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which there are cigarette butts and trash on the grounds of both structures, front/back yards, and patio area. Trash cans did not have lids which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall clean the surroundings and designate a smoking area for the clients. Administrator will submit photos of the cleaned areas to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which there were items like grocery carts filled with trash, used cans and bins outside house #2 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall ensure that the property is cleaned and items had been removed by submitting photos to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which there were no window screens in some of the windows in both structures. LPA observed cracked glass window in front of House #1 and was broken. Window sill/moldings were broken and chipped in bathroom #2 in House #2 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall ensure that the broken and missing items such as broken window glass, window screens and window sill/moldings had been fixed and installed by submitting photos and receipts to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that all the clients bedrooms were not equipped with reading lights/lamps which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall provide lamps/reading lights to the clients rooms and submit photos and receipts to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that all the clients bedrooms were not equipped with side/night tables which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator shall provide the night/side tables to the clients rooms and submit photos and receipts to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80022(a)
Plan of Operation
(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in which the facility has no plan of operation in place which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administrator will complete a plan of operation that includes infection control plan and send proof to CCL/LPA by POC date.

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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 07/18/2023 03:16 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/18/2023 at 02:07 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the Administrator did not comply with the section cited above in that the facility does not have a computer or tablet available for clients' use which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Administartor shall ensure that clients have access to computers or smart phones or tablets for the clients use at the facility. Administrator shall submit a plan and proof that this has been provided to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the facility has not conducted any emergency drill since 5/11/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Administrator shall ensure that disaster drills are conducted at least every six (6) months and submit the trainings conducted with the topics and signed by all staff present to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


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