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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592149
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:23:55 PM

Document Has Been Signed on 07/11/2024 03:23 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:LOVING CARE GUEST HOMEFACILITY NUMBER:
191592149
ADMINISTRATOR/
DIRECTOR:		SABIO, MARILYNFACILITY TYPE:
735
ADDRESS:15027 - 15031 BLACKWOOD STTELEPHONE:
(626) 917-2312
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 12CENSUS: 10DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Marilyn Sabio TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Marilyn Sabio and the purpose of the visit was discussed. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has a plan of operation and infection control plan in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are adhering to infection control requirements.

Operational Requirements: The facility is licensed to care for up to (12) Adults, ages 18 through 59, ambulatory only. Fire clearance approves Six (6) clients in 15027 building and six (6) clients in house 15031. Sufficient space for activities observed. Last Fire Drill was conducted on 2/3/2024. Signal System Inoperable.

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) client bedrooms, (1) staff room, 2 full bathrooms, living room, dining area, kitchen, laundry area, office area front porch, patio and detached garage for storage. Currently, there are ten (10) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector and required furniture, linen, linen, and sufficient closet space. Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper. LPA observed all windows to be in good repair. Exit doors are free of obstruction and there are no pools or large bodies of water. Backyard was inspected and observed. Detached garage was toured. The garage was locked and inaccessible to clients in care. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. Three (3) fire extinguishers last inspected April 2024. Smoke alarms and carbon monoxide were tested and operational. There are no firearms or weapons stored at the facility. Water temperature readings measured at 133 and 127 in client bathrooms, which is not in line with title 22 regulation.



*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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 4
Document Has Been Signed on 07/11/2024 03:23 PM - It Cannot Be Edited


Created By: Jose Villalobos On 07/11/2024 at 02:25 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: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as faucets in client bathroom #1 and #2 had water temperature measuring 133 degrees and 127 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Water temperature was lowered by the end of the visit. Deficiency is cleared
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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/11/2024 03:23 PM - It Cannot Be Edited


Created By: Jose Villalobos On 07/11/2024 at 02:25 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: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the singal system from the back house to the main house is not operable. The front home intercom is broken and will not receive signals from client rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee/Administrator to provide LPA with plan to replace the current broken signal system and complete either repairs or replacements by POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee/ Administrator to provide LPA with the First Aid/CPR certification for both themselves and Staff #2 by the 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:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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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: LOVING CARE GUEST HOME
FACILITY NUMBER: 191592149
VISIT DATE: 07/11/2024
NARRATIVE
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Staffing: A total of two (2) 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 two (2) staff. Proof of staff training, health clearance, vaccinations. First Aid/ CPR Certifications on file are expired. Administrator could not locate most recent certificates. Administrator certificate is valid and will expire on 4/28/2026.

Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. LPA was able to conduct interview with (1) Clients in care.



Client Records-Incident Reports: LPA reviewed six (6) Client files. Client files are centrally stored in 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 for all (6) Files.

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. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free of pests. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: Medications stored and locked inaccessible to clients in care. LPA reviewed five (5) Client Medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician

Incidental Medical Services: There are no clients at this home with incidental medical services nor have a restricted health condition. No clients with postural supports. No Clients with prohibited health conditions.

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

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview conducted and a copy of the appeals rights and this report was provided to Marilyn Sabio.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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