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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592733
Report Date: 02/17/2023
Date Signed: 02/17/2023 05:34:05 PM

Document Has Been Signed on 02/17/2023 05:34 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:L.A HOMEFACILITY NUMBER:
191592733
ADMINISTRATOR:SALVADOR, ERLINDAFACILITY TYPE:
735
ADDRESS:13881 SARANACTELEPHONE:
(562) 941-2830
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Erlinda Salvador TIME COMPLETED:
10:40 AM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Erlinda Salvador who assisted with the visit.

LPA Rea discussed infection control practices with Ms. Salvador, toured the facility inside and out, reviewed food supply, staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilets. Showers also have non-skid materials. The hot water temperature measured at 133.9 degrees F in the kitchen sink, 134.7 degrees F in the bathroom sink, and 90.9 degrees F in second bathroom . The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors & carbon monoxide detector were tested and operational. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Deficiencies on 809-D. Exit interview conducted, copy of report, and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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Document Has Been Signed on 02/17/2023 05:34 PM - It Cannot Be Edited


Created By: Angelica Rea On 02/17/2023 at 10:04 AM
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: L.A HOME
FACILITY NUMBER: 191592733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2023

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


This requirement is not met as evidenced by: LPA observed that water temperature measured 133.9 degrees F in the kitchen sink, and 134.7 degrees F in the bathroom sink, and 90.9 degrees F in the second bathroom sink.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 water temperature(s) measured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Administrator will ensure the water temperature measures between 105 degrees F and 120 degrees F as required. Administrator will send LPA a water temperature log for 5 days as proof that the water temperature has been corrected, by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
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