191593145-3-2-2023-28-AS-JBAE-CPK3VS-20230302173538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191593145
Report Date: 03/02/2023
Date Signed: 03/02/2023 05:36:09 PM

Document Has Been Signed on 03/02/2023 05:36 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:	RAMONA GUEST HOME - BELLFLOWER		FACILITY NUMBER:	191593145
ADMINISTRATOR:	KANIEL, STANLEY		FACILITY TYPE:	735
ADDRESS:	9555 RAMONA ST		TELEPHONE:	(562) 867-1002
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 29		CENSUS: 22	DATE:	03/02/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Stanley Kaniel		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/02/2023 at 1:00 p.m., Licensing Program Analyst (LPA) Jewel Baptiste, Licensing Program Manager (LPM) Lisa Hicks, and Regional Manager (RM) Araceli Ramirez conducted an unannounced Case Management visit to ensure the Licensee is in compliance with Title 22 regulations, and to follow up on physical plant deficiencies observed during the Plan of Correction (POC) visit conducted on 2/21/2023. The purpose of the visit was explained to Licensee Stanley Kaniel. A tour of the facility was conducted. On 2/21/2023, the Licensee requested additional time to make repairs to the facility. LPA provided additional time to the Licensee to make the repairs. LPA observed that some of the client’s bedrooms still need curtains- The Licensee stated the completion date of 2/26/2023. During the visit RM, LPM and LPA had a discussion with Licensee about the facility closure. Mr. Kaniel stated the facility is expected to be listed to be sold within 3-4 weeks and will update CCLD throughout the process. Report continued on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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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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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

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During today’s visit, RM, LPM, and LPA observed the following:

Building #1
· Room #1
1. Bedrails were observed leaning against the wall and not on the bed.
2. Blinds were in disrepair.
3. Resident dresser was in disrepair.
4. Ceiling fan has accumulated dust and needs cleaning.
· Bathroom for room #1
1. Bathroom door was broken and in disrepair.
2. Floor tiles in disrepair and need to be replaced.
3. Bathroom cabinet was in disrepair and needs replacing.
4. Shower door was missing.
5. Bathroom walls was in disrepair and needs painting.
· Room#2
1. Bed was missing padding, sheets, and a blanket.
2. Ceiling fan has accumulated dust and needs cleaning.
3. 2^nd bed was missing the appropriate bed rails.
4. Closet storage doors need to be operational.

Report Continued on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

NARRATIVE

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· Bathroom
1. Floor tiles in disrepair and need to be replaced.
2. Bathroom tub in disrepair.
3. Light fixture is exposed and needs a cover.
4. Wiring is exposed and needs to be secured.
5. Medicine cabinet mirror was broken and in disrepair.
· Bedroom#3
1. Bedroom curtains/blinds were missing.
2. Bed was missing a mattress pad, sheets, and blankets.
3. Nightstands have signs of wear and tear and will need replacing.
4. Ceiling fan has accumulated dust and needs cleaning.

Building #2
· Bedroom #5
1. Heater was in disrepair with exposed wiring.
2. Ceiling fan was in disrepair and needs replacing
3. Bedroom floors were covered in dirt and need cleaning.
4. Resident mattress was in disrepair.
5. Bedrails were in disrepair.
6. Curtains/blinds was missing and need replacing.
7. Windows screen was missing and needs replacing.
8. Room is currently being renovated; client will be relocated to an empty bed in

Report Continued on 809 C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

NARRATIVE

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building #2
· Bedroom #6
1. Toilet was in disrepair and needs replacing.
2. Sink, and shower was covered in stains and needs cleaning.
3. Heater was in disrepair with exposed wiring.
4. Light fixture is exposed and needs a cover.
· Bedroom #4
1. Heater was in disrepair with exposed wiring.

Building #3
· Bedroom#7
1. Dresser was broken and needs replacing.
2. Light fixture is exposed and needs a cover.
3. Nightstands have signs of wear and tear and will need replacing.
4. Floor tiles in disrepair and need to be replaced.
5. Bedroom paint in disrepair and needs to be repainted.
· Bedroom#8
1. Bed was missing a mattress pad.
· Bathroom for rooms #7 and #8
1. Bathroom is missing a screen.
2. The toilet seat cover does not fit the toilet and needs replacing.
3. Light fixture is exposed and needs a cover.

Report Continued on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 8

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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

NARRATIVE

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· Bedroom #9
1. Floor tiles are in disrepair and needs to be replaced.
2. Dresser was broken and needs replacing.
3. Vent accumulated dust and dirt and needs cleaning.
4. Light fixture is exposed and needs a cover.
5. Wiring was exposed and needs to be secured.
· Bedroom #10
1. Bed sheets were worn out and needs to be replaced or washed.
· Bathroom for room #9 and #10
1. Bathroom screen was broken and in disrepair.
2. Wiring was exposed and needs to be repaired.
3. Light fixture is exposed and needs a cover.
· Bedroom#11
1. Floor tiles in disrepair and need to be replaced.
2. Light fixture is exposed and needs a cover.
· Bedroom #12
1. Above the resident’s bed, a light fixature was observed that needs removal due to potential hazard.
2. Vacant bed has multiple mattresses that need removal.
3. Nightstand was broken and needs replacement.
· Bathroom for room #11 and #12
1. Floor tiles were in disrepair and need to be replaced.
2. Window is missing a screen and needs a replacement.
Report Continued on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 5 of 8

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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

NARRATIVE

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· Bedroom#13
1. Floor tiles were in disrepair and need to be replaced.
2. Bedroom is missing a curtain and needs to be replaced.
· Bathroom for bedroom #13
1. Floor tiles were in disrepair and need to be replaced.
2. Bathroom needs additional lighting.
3. Medicine cabinet mirror is broken and needs replacing.
4. The light above the bathroom sink was broken and in disrepair.
· Bedroom #14
1. Floor tiles were in disrepair and need to be replaced.
2. Resident mattress needs replacing, and the hospital bed needs to be removed.
3. The bed is missing a bed frame, which needs to be added.
· Bedroom #15
1. Floor tiles in disrepair and need to be replaced.
2. Hospital bed needs to be removed.
· Bathroom for bedroom #14 and #15
1. Toilet was clogged and in disrepair.
2. Bathroom screen was missing and needs replacing.

Report Continued on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 6 of 8

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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
	VISIT DATE: 03/02/2023

NARRATIVE

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· Staff Bathroom
1. Bleach bottles need to be removed.
· T.V Room
1. Floor tiles were in disrepair and need to be replaced.
2. Couches were in disrepair and need replacing.
3. Window is missing screens.
· Dinning room
1. Floor tiles were in disrepair and need to be replaced.
· Kitchen
1. Floor tiles were in disrepair and need to be replaced.
2. Facility is missing a menu which needs to be posted.
3. Facility needs 2-3x’s more can foods.
· Surrounding the building
1. Sofa cushions needs to be removed.
2. Facility will replace water filled bleach bottles and acquire the appropriate door stops.
3. Facility will remove debris such as crates, kitchen stand and metals from the side of the building.
4. Facility will remove orange container outside of food storage area.

California Code of Regulation, Title 22 are being cited on the attached LIC809D and Civil Penalties assessed. Exit Interview Conducted with Licensee Stanley Kaniel / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/02/2023 05:36 PM - It Cannot Be Edited

Created By: Jewel Baptiste On 03/02/2023 at 04:49 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: RAMONA GUEST HOME - BELLFLOWER	FACILITY NUMBER: 191593145
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/02/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	Buildings 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:	1 2 3 4 5 6 7	LPA added an extension on 2/21/2023 for the Licensee to have curtains for all resident rooms update by 2/26/2023. Licensee will ensure all residents has the appropriate curtains by POC due date and send photo proof to CCLD.
	8 9 10 11 12 13 14	Based on Observations, the Licensee has not put up the required curtains due on 2/26/2023. During the visit LPA observed in room# 1, and 3 is still missing the appropriate curtains.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Jewel Baptiste

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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