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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592571
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:10:33 PM

Document Has Been Signed on 01/14/2025 04:10 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:PMC II GUEST HOMEFACILITY NUMBER:
191592571
ADMINISTRATOR/
DIRECTOR:		QUITORIANO, PRESCILAFACILITY TYPE:
740
ADDRESS:12802 CURTIS & KING ROADYTELEPHONE:
(562) 868-1435
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ofelia Tanglao - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Ofelia Tanglao and explained the purpose for today’s visit. The facility is licensed to serve 6 Residents ages 60 and above, (4) of which may be non-ambulatory in rooms 1 & 3 only, there is a hospice wavier for 2. The facility currently has 4 residents, (1) of which is using hospice services.

The facility is a single-story home located in Norwalk, Ca. A tour of the facility includes: 5 Resident bedrooms, 3 bathrooms (1 bath is within a private room), 2 dining areas, 2 kitchens, 2 living rooms, laundry area, front yard, back yard and attached garage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:


Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan.
Operational Requirements: Administrator was not able to provide LPA with a copy of the required valid liability insurance, and the facility is operating outside of what they are licensed for and what their fire clearance has approved as there is 1 bedridden resident in the facility, citations will be issued in detail on the LIC809-D page. Civil Penalties will be issued on the ambulatory status for having 1 bedridden resident.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. LPA observed cleaning solutions, and a knife stored in an unlocked cabinet during tour, citation will be issued in detail on the LIC809-D page. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 01/14/2025 04:10 PM - It Cannot Be Edited


Created By: Tena Herrera On 01/14/2025 at 02:57 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: PMC II GUEST HOME
FACILITY NUMBER: 191592571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and residents record review, the licensee did not comply with the section cited above as there is currently 1 resident at the facility who is bedridden, facility does not have fire clearance nor are they approved for bedridden residents, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator/Licensee to either relocate resident to a facility that is licenesed and has fire clearance for bedridden residents (proof of relocation along with detailed information of facility that resident will be transferred to must be provided to LPA) or begin the process of being approved for bedridden resident(s) by submitting an updated LIC200 and updated facility sketch to LPA by tomorrow 1/15/25. Either option has a due date of 1/15/25. Proof must be emailed to LPA at tena.herrera@dss.ca.gov
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 aboveas during facility tour LPA found disinfectes in both main resident restrooms in unlocked cabinets under sink, there were unlocked disinfectants in staff kitchen, in room # 2 there was a bottle of raid (insect cleaner) in an unlocked cabinet within private bath and an kife was observed in an unlocked drawer in the resident kitche, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Staff removed the disinfectants in staff kitchen and raid bottle, and placed with other disinfectants in resident bathroom, both resident bathroom cabinets with disinfectants were locked by staff during visit. The kife was also removed and placed in a locked drawer during visit. Administraor/Licensee to conduct a training with all staff on proper storage of disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents, and submit proof of training (participant list with signatures and date training was conducted) to LPA via email by 1/28/25. tena.herrera@dss.ca.gov
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/14/2025 04:10 PM - It Cannot Be Edited


Created By: Tena Herrera On 01/14/2025 at 02:57 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: PMC II GUEST HOME
FACILITY NUMBER: 191592571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with administator, the licensee did not comply with the section cited above as proof of liability insurance was not able to be provided to LPA during visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator/Licensee to email LPA proof of the required (valid) liability insurance by POC due date. tena.herrera@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 staff was oberved to have an expired first-aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator/Licensee to email LPA a copy of the valid first-aid certificate for Staff #2 by POC due date. Tena.herrera@dss.ca.gov
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PMC II GUEST HOME
FACILITY NUMBER: 191592571
VISIT DATE: 01/14/2025
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff has criminal record clearance, and training documented in personnel files however, 1 staff was observed to be missing the required valid First-Aid certificate, citation will be issued in detail on the LIC809-D page. There were a total of 4 staff files reviewed. Administrator Emma Maralli-Tamayo Administrator certificate expires on 12/20/25.
Resident Records-Incident Reports: Resident files are kept in a secure location (within staff room/office) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on the LIC809-D pages.

Immediate $500.00 Civil Penalties were issued during visit.

Exit interview held and a copy of the report, LIC421IM (Civil Penalty Assessment), and appeal rights will be emailed to administrator at pmcguesthome1@gmail.com / emzh24@yahoo.com.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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