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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592571
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:17:29 PM

Document Has Been Signed on 01/24/2023 02:17 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:PMC II GUEST HOMEFACILITY NUMBER:
191592571
ADMINISTRATOR:QUITORIANO, PRESCILAFACILITY TYPE:
740
ADDRESS:12802 CURTIS & KING ROADYTELEPHONE:
(562) 868-1435
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 3DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elizabeth Almeron, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analysts (LPAs) Galarza and Erik Zaragoza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Ofelia Tanglao and explained the purpose of the visit. Administrator Elizabeth Almeron arrived at the end of the visit. There are three (3) elderly residents in the home. A Hospice Waiver for two (2) residents is in place. The facility is a single story home licensed to serve 6 residents age 60 and above; of which 4 may be non-ambulatory in rooms #1 & #3. It consists of 4 resident bedrooms, 2 staff rooms, 1 storage room, 3 bathrooms, 2 dining rooms, 2 kitchens, 2 living rooms, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 12/18/22. Administrator certificate expires 2/26/2023.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • If needed room #2 is designated as the COVID-19 isolation room.
  • A posted Emergency Disaster Plan was observed.
  • Three (3) centrally stored resident medication records were reviewed and observed to be locked.
  • Staff were observed wearing mask. Residents were not observed wearing masks.
  • The kitchens were inspected and have sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • There is a live-in staff with a minor child. The minor will turn 18 years old in Feb. 2023. Administrator has been instructed to obtain fingerprint criminal background clearance of the individual.
  • An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible. The plan should be reviewed and updated as necessary. The licensee has agreed to submit their Infection Control Plan by [up to 60 days from inspection].
No deficiencies were cited. A technical assistance advisory note was issued.
Exit interview was conducted with Administrator Elizabeth Almeron. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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