197607320-12-5-2023-28-AS-JBAE-CY8VDV-20231205152124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607320
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:21:31 PM

Document Has Been Signed on 12/05/2023 03:21 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:	CERRITOS VILLA 1		FACILITY NUMBER:	197607320
ADMINISTRATOR:	JULIO NAVALLO		FACILITY TYPE:	740
ADDRESS:	16231 DRYCREEK LANE		TELEPHONE:	(562) 404-0767
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 5	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	RN Alda Farren		TIME COMPLETED:	03:40 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 12/05/23 at 8:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Cerritos Villa I. Upon arrival LPA was greeted by Direct Support Professional (DSP) Cristina Riego who contacted the RN consultant Alda Farren. This home is licensed to serve elderly residents aged 60 and above. All residents can be non-ambulatory. Facility approved to accept or retain one resident on hospice. Facility is 87724 compliant. There is no staff room. Therefore, facility will provide 24-hour awake staff. No staff room, therefore, facility will provide 24-hour awake staff. There were (3) residents in care during the time of this visit, the other (1) resident were at the day program and (1) resident was hospitalized. The last emergency disaster/fire drill was conducted on 11/18/23. The Administrator Certificate expired on 8/31/2023 #6059713740. The facility was unable to provide proof of a valid Administrator Certificate. LPA Baptiste also reviewed the pending and active administrator certificates online and was not able to find proof of valid Administration certificate. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (5) resident files, medications, and medication administration records for (4). This home contains 4 bedrooms, 2 bathrooms, living room, office, kitchen, dining room and an attached garage. LPA toured the physical plant with the RN consultant. and observed all (4) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 121.8F-127.2F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in hallway and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were unsecured in kitchen cabinet and backyard. The cleaning agents and toxins was unsecured in the bathroom, kitchen, and backyard. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. LPA reviewed medications and observed some medications was marked as given before time or medications was missing for the wrong time frame. During file review LPA confirmed Staff S1 and S2 was not associated to the facility. (Report continued on LIC809C.)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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

Document Has Been Signed on 12/05/2023 03:21 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: CERRITOS VILLA 1	FACILITY NUMBER: 197607320
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above in 2 out of 2 bathrooms water temperature tested between 121.8- 127.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	The Licencee will adjust the water temperature and send photo proof of the log to LPA by POC due date.

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
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above in which cleaning supplies and toxins was left unsecured in bathroom, kitchen and backyard, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	The licencee will ensure all toxins, cleaning supplies and sharps are secured at all times. Please conduct staff in service and submit the documents to LPA by 12/11/2023. This citation was cleared during the visit.

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	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 12/05/2023 03:21 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: CERRITOS VILLA 1	FACILITY NUMBER: 197607320
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

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
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above in which LPA observed medications for R1 was signed off as given before time and medications was missing, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	The Licencee will conduct inservice on medication Administration with staff and send training to LPA by 12/11/2023.

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (2) Request a transfer of criminal record clearance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above in staff S1 was not cleared or associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	The licensee will associate the staff in question via Guardian and provide a copy of the facility association list via email by POC due date. The licensee will also understand employees has to be associated before working at the facility.

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	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/05/2023 03:21 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: CERRITOS VILLA 1	FACILITY NUMBER: 197607320
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(13)(B)1

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which LPA observed the administrator certificate expired on 8/31/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2023
	Plan of Correction
1 2 3 4	The licensee will submit hours of course taken to renew certifacte and submit the trainings to Sacramento by POC due date,

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 4 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: CERRITOS VILLA 1	FACILITY NUMBER: 197607320
	VISIT DATE: 12/05/2023

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
26
27
28
29
30
31
32

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

The following Deficiencies were cited on the LIC809D, and civil penalties was assessed. Exit interview conducted with Alda Farren, RN consultant, a copy of this report was provided, and Appeal rights given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5