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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607320
Report Date: 11/02/2024
Date Signed: 11/02/2024 03:41:56 PM

Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CERRITOS VILLA 1FACILITY NUMBER:
197607320
ADMINISTRATOR/
DIRECTOR:		JULIO NAVALLOFACILITY TYPE:
740
ADDRESS:16231 DRYCREEK LANETELEPHONE:
(562) 404-0767
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:27 AM
MET WITH:Caregiver Gloria RoxasTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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LPA was met by Caregiver Gloria Roxas and explained the purpose of the visit. Administrator Julio Navallo arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one (1) may be bedridden and one (1) hospice approved. During today’s visit it was observed facility had two (2) bedridden residents without approved fire clearance civil penalties assessed.

The home is located in a residential neighborhood, is a single-story home on a cul-de-sac The home contains (4) bedrooms, (2) bathrooms, living room, dining room, kitchen, and garage.

LPA toured the facility and observed the following: Each resident’s bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Front door auditory device was not working at time of visit. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has two (2) fully charged fire extinguishers which is kept in the kitchen and hall. Cleaning supplies and toxic substances were observed to be accessible to residents in cabinet under kitchen sink and bathroom #1 deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The two bathrooms contain a working toilet, basin and water faucet, shower with grab bar, shower chair, and bathmat. The hot water temperature in the bathrooms were measured between in the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies.
Tony VasalloTELEPHONE: (323) 981-3977
Christian GutierrezTELEPHONE: 323-981-3984
DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2024
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 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning supplies were observed under kitchen sink and bathroom #1 unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2024
Plan of Correction
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Caregiver locked cabinet in kitchen and removed comet cleaner at time of visit. Administrator will conduct training and send to LPA by email.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 one (1) out of six (6) residents R3 medication were in refrigerator not in a locked box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2024
Plan of Correction
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Administrator agrees to purchase lock box for medication and send LPA pictures by email.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 one (1) out of six (6) residents R4 medication was not documented correctly and Administartor could not indicate when medication was started which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2024
Plan of Correction
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 Administrator will conduct inservice training on medication with staff and sent to LPA by POC due date.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

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 facility has two (2) bedridden residents operating out of required scope fire clearance approved for one(1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2024
Plan of Correction
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Administrator will certify what steps he will take to address to being over capacity.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

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 two residents did not have hospice waiver facility has hospice clearance for one which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2024
Plan of Correction
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Administartor will apply for hospice waiver increase and will certify what steps he will take to address being over capacity.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

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 record review, the licensee did not comply with the section cited above facility did not have liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator will renew insurance and send to LPA by email.
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 front door auditory did not work which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator will replace batteries or device and send LPA video by text.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 two (2) out of four (4) staff did not have CPR/First AID training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administartor will send S2 and S3 CPR/ First Aid training.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 two (2) out of two (2) residents R4 and R6 did not have current Physicians reports which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administartor will send LPA current Physicians reports 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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/02/2024 03:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

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 two (2) out of three (3) residents did not have a hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator will send hospice care plan to LPA.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

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 three (3) out of four (4) staff did not have training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator will send all training to LPA 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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320
VISIT DATE: 11/02/2024
NARRATIVE
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One (1) out of four (4) Staff files were reviewed and included Criminal clearance record, CPR, and health screening with TB. Two staff did not have current CPR. Five (5) out of Six (6) residents files were reviewed and included physicians report, TB clearance. Two residents were missing Physicians reports and two were missing hospice care plan. Fire/earthquake drill was conducted in October of 2024 Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all residents and one (1) out of six (6) are not given out properly. During Visit LPA observed medication in refrigerator not in locked box. Facility did not have current liability insurance.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Julio Navallo.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2024
LIC809 (FAS) - (06/04)
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