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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607462
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:47:30 PM


Document Has Been Signed on 07/11/2023 03:47 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:ALAIN CRESTFACILITY NUMBER:
197607462
ADMINISTRATOR:ERWIN JUN S. DE GUZMANFACILITY TYPE:
740
ADDRESS:18936 STEFANI AVENUETELEPHONE:
(562) 331-8880
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 3DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Erwin De GuzmanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/11/23 at 12:30 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Alain Crest. Upon arrival LPA was greeted by Direct Support Professional (DSP) Glycie Llebado who contacted the Administrator, Edwin De Guzman, at 12:49 p.m. to assist with today's visit. This home is licensed to serve elderly residents age 60 and above. Facility fire cleared for all Non-ambulatory. Facility approved to accept or retain one resident on hospice. There were (3) clients in care during the time of this visit. The Administrator Certificate expired on 5/13/2022 #6017385740. LPA was not able to fine administrator name on the active or pending list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, and medications.

This home contains 3 bedrooms, 2 staff bedrooms, 2 bathrooms, living room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. LPA observed residents R1 through R3 with half bedrails, but no doctors’ orders was found in their files. The two bathrooms contain a working toilet, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 125.6 degrees*F 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 kitchen 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 with knives secured and locked underneath kitchen sink with cleaning agents and toxins. 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. During the tour LPA observed a roach crawling on kitchen cabinet. Administrator stated the facility has contacted pest control.
(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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 07/11/2023 03:47 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: ALAIN CREST
FACILITY NUMBER: 197607462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

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
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Based on observation, the licensee did not comply with the section cited above in bathroom #1 water temperature was tested at 125.6 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator will adjust the temperature and keep a log for 3 days and send photo proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 which R3 had no record of dosages, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Administrator will ensure R3 has physcians order and send proof 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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:47 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: ALAIN CREST
FACILITY NUMBER: 197607462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

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 2 out of 3 residents medications was missing labels, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Facility will ensure all resident medications has labels and send photo proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(c)(1)
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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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 which R3 did not have written orders from there physcian, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Facility will ensure R3 has written physcians orders and send proof 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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:47 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: ALAIN CREST
FACILITY NUMBER: 197607462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

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 whoich LPA did not observe educational requirements for the administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The administrator will update their file and add educational requirements and send proof to LPA by POC due date
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 which R1-R2 did not have admissions agreement in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The administrator will update all resident files and send proof 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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:47 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: ALAIN CREST
FACILITY NUMBER: 197607462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

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 which resident files did not have functional and capabilities assessments, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The administrator will update all resident files and send proof to LPA by POC due date.
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 observation, the licensee did not comply with the section cited above in which residents R3 was missing their physcians report, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The administrator will update all resident files and send proof 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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 07/11/2023 03:47 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: ALAIN CREST
FACILITY NUMBER: 197607462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 which LPA observe a roach on kitchen cabinent, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Administrator will ensure the facility is free from pest and send proof to LPA by POC due date.
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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


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: ALAIN CREST
FACILITY NUMBER: 197607462
VISIT DATE: 07/11/2023
NARRATIVE
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The outdoor grounds were toured and inspected, with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

Medications was observed to be missing labels for all three residents and R2 was missing PRN medication (Diclofenac). LPA observed R3 did not have physicians’ orders.

During file review R1 and R2 files contained physicians report only and R3 file contained their admissions agreement. Administrator file only had criminal record statement.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6. Exit interview conducted with Erwin De Guzman, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7