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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607106
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:24:10 PM


Document Has Been Signed on 09/12/2023 05:24 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:PAULA'S GUEST HOME, INC.FACILITY NUMBER:
197607106
ADMINISTRATOR:CHONA M. CRUZFACILITY TYPE:
740
ADDRESS:16439 PRUDENCIA DRIVETELEPHONE:
(562) 943-3333
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 6DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Chona Cruz, Administrator TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Chona Cruz. There are currently 6 elderly Dementia residents 60 years and older residing in the facility. One (1) resident is receiving hospice care, and two (2) residents receive home health services. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

Infection Control:

  • Visitors are still screened for COVID-19 and required to sign in. The facility has an Infection Control Plan and Covid-19 Mitigation Plan. Infection control practices and Personal Protective Equipment (PPEs) were observed.


Operational Requirements:
  • A current Plan of Operation was reviewed.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 5 is approved.
  • A fire clearance for 6 non-ambulatory adults 60 and over is in place.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current and expires 6/29/2024.
  • A surety bond is not applicable. Facility does not handle resident's money.


***See next page for report narrative.***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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 5


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: PAULA'S GUEST HOME, INC.
FACILITY NUMBER: 197607106
VISIT DATE: 09/12/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood consisting of 4 resident bedrooms (2 shared and 1 private), 1 staff room, 3 bathrooms, living room, dining room, kitchen, laundry room, outdoor patio area with patio furniture, and 2 car detached garage presently being used as storage room. Staff room next to resident room #4 is being renovated. Resident room # 5 is presently being used as a live-in staff room for staff (S2 & S3).
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were locked.
  • Two bathrooms had unlocked incontinence care/mouth wash, medicated body powder, hand sanitizer, and disinfectant cleaning supplies. Citation was issued.
  • The backyard and side yards had unlocked sharp tools, gardening supplies, paint can, insect/roach spray, and kitchen cleaning products. Citation was issued.
  • The facility has two (2) fully charged fire extinguishers and a fire pull alarm.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit.

Staffing:
  • A total of 8 staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 1/24/2023. Licensee/Administrator provided proof that training was submitted to certification unit and is awaiting receipt of current certificate.
  • Personnel files were reviewed. Criminal Background Clearance, staff training, 1st Aid/CPR, and health screening/TB clearance was checked.

Resident Records/Incident Reports:
  • A total of three (3) resident files were reviewed. Dementia resident (R1's) Physician Report is not updated. Citation was issued.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

***narrative continues next page***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: PAULA'S GUEST HOME, INC.
FACILITY NUMBER: 197607106
VISIT DATE: 09/12/2023
NARRATIVE
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Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Minimal indoor and outdoor activities are performed.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are in place.

Incident Medical and Dental:
  • Centrally Stored Records for medications are kept. Facility does not use Medication Administration Records (MARs). The facility does not have resident (R1's) PRN Acetaminophen 500 mg medication, and the centrally stored record is missing prescription #, date of Rx, and expiration date. Citation was issued.
  • Medical and dental transportation is provided by family members.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place and was posted today.
  • The last emergency disaster drill was conducted on 7/14/23.

Residents with Special Health Needs:
  • One (1) resident receives hospice care and two (2) residents are enrolled in home health services. Hospice Care Plan was reviewed.
  • Postural supports/ Hoyer lift is used by one resident. Physician order is on file.
  • Full and half bed rails for mobility assistance were observed in resident beds.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.
Exit interview was conducted with Administrator Chona Cruz. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2023 05:24 PM - It Cannot Be Edited

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: PAULA'S GUEST HOME, INC.
FACILITY NUMBER: 197607106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 in that Dementia resident (R2's) physician report is dated 2/8/2022; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Administrator shall submit a current MD report for R2.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 above in that the backyard and side yards had unlocked sharp tools, gardening supplies, paint can, insect/roach spray, and kitchen cleaning products; which poses a potential health and safety risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Submit pictiure proof of correction.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/12/2023 05:24 PM - It Cannot Be Edited

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: PAULA'S GUEST HOME, INC.
FACILITY NUMBER: 197607106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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 above in that two bathrooms had unlocked incontinence care/mouth wash, medicated body powder, hand sanitizer, and disinfectant cleaning supplies; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
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Submit picture proof of correction by tomorrow.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:


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 above in that PRN medication supply of Resident (R1's) Acetaminophen 500 mg has not been filled, and centrally stored record is missing prescription #, date of Rx and expiration date; which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
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Administrator shall submit a written plan stating how this deficiency will be correct. Proof of staff training and proof the medication was obtained shall be submitted.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5