<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607445
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:40:23 PM

Document Has Been Signed on 03/10/2022 12:40 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:BLUE EAGLE VILLASFACILITY NUMBER:
197607445
ADMINISTRATOR:ABRAHAM VALDEZFACILITY TYPE:
735
ADDRESS:1630 N. BRIGHTON STREETTELEPHONE:
(818) 557-7239
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 6DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Gerardo Reyes, LicenseeTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Licensee Gerardo Reyes and explained the purpose of the visit. There are five (5) clients ages 18-59, and one (1) age 60 and over. The facility is a single story home located in a residential neighborhood that is licensed for six clients [four (4) non-ambulatory and two (2) ambulatory].The home consists of five (5) bedrooms [1 bedroom is a staff bedroom], three (3) bathrooms, dining room, kitchen, living room, recreation area with laundry area, staff room, attached garage, backyard, front yard patio area, and an office with a staff bed.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. LPA was not screened upon entry and did not observe visitor screening area/protocols in place. DSP acknowledged screening is not in place.
  • Facility has an approved COVID-19 mitigation plan. COVID-19 infection control signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing; with the exception of 1 bathroom.
  • Room #3 has been designated as a COVID-19 isolation room if needed
  • Three (3) centrally stored resident medication records were reviewed.
  • Residents in care do not wear masks because they lack hazard awareness and impulse control.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • There was discarded furniture in the backyard area.
  • Emergency disaster drills have not been conducted since the beginning of the pandemic.
Deficiencies were cited.
Exit interview was conducted with Licensee Gerardo Reyes. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 4
Document Has Been Signed on 03/10/2022 12:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/10/2022 at 11:34 AM
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: BLUE EAGLE VILLAS
FACILITY NUMBER: 197607445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1550(c)
Suspension and Revocation
(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

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 that LPA was not screened upong entry, and did not observe screening protocols, and visitor sign-in sheets in place. Handwashing posting was not observed in 1 bathroom DSP staff acknowledged screening, and sign-in records have not been implemented, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
1
2
3
4
Licensee shall submit picture proof that a COVID-19 screening station, and visitor sign-in record log has been put into place. The POC is due tomorrow.
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
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2022 12:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/10/2022 at 11:34 AM
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: BLUE EAGLE VILLAS
FACILITY NUMBER: 197607445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that discarded furniture was observed in the backyard area, and corridor that leads to the backyard from the rear exit door. Items observed were: toilet, broken chairs, broken patio furniture, mattress frames, and wooden planks; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
1
2
3
4
Licensee shall submit picture proof of correction 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
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2022 12:40 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/10/2022 at 11:53 AM
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: BLUE EAGLE VILLAS
FACILITY NUMBER: 197607445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster and Mass Casualty Plan

Disaster drills shall be conducted at least every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews conducted, the licensee did not comply with the section cited above in that staff acknowledged that disaster drills have not been conducted per protocol since early 2020 when the pandemic began. During today's visit, LPA instructed staff to test the fire pull alarm that is connected to facility smoke detectors. DSP staff did not know how to operate the control switch, to turn it off; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
1
2
3
4
Licensee shall conduct staff training, and submit proof that the disaster drill was completed.
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
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4