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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603456
Report Date: 05/21/2022
Date Signed: 05/23/2022 01:45:26 PM

Document Has Been Signed on 05/23/2022 01:45 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:ALICIA CARE CENTERFACILITY NUMBER:
197603456
ADMINISTRATOR:PEGGY PAYNE WALTERSFACILITY TYPE:
735
ADDRESS:1823 VASSAR AVE.TELEPHONE:
(818) 240-5171
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY: 6CENSUS: 6DATE:
05/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelica Quintero TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Caregiver,Angelica Quintero who allowed entry into the facility. Administrator, Melvin Alvarez Mendoza arrived at the facility a short time later.

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

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 bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 124.3 degrees Fahrenheit, The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, which were tested. Carbon monoxide detector was also observed, and tested. 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 cited on 809-D. Exit interview held and a copy of the report and appeal rights were provided to Mr. Mendoza.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2022
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 05/23/2022 01:45 PM - It Cannot Be Edited


Created By: Angelica Rea On 05/21/2022 at 03:36 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: ALICIA CARE CENTER
FACILITY NUMBER: 197603456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA observed water temperature measured at 134.4 degrees Fahrenheit.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Licensee will ensure that water temperature measures between 105 degrees and 120 degrees Fahrenheit as required. Licensee will send LPA Rea a log with temperature readings for 3 days by POC due date.
Type A
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by: LPA observed that 4 smoke detectors were not operational throught the facility.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 4 smoke detectors observed throughout the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Licensee will ensure that all smoke detectors are operational by POC due date. Licensee will send a copy of receipts for purchase of new smoke detectors and photos that they have been installed by 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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2022


LIC809 (FAS) - (06/04)
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