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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607612
Report Date: 11/19/2022
Date Signed: 11/19/2022 05:08:23 PM


Document Has Been Signed on 11/19/2022 05:08 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:MONACO CREST GUEST HOMEFACILITY NUMBER:
197607612
ADMINISTRATOR:CARINA DEMMANFACILITY TYPE:
740
ADDRESS:15225 METROPOL DRIVETELEPHONE:
(562) 693-9470
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 6DATE:
11/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Carina Demman- AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with Administrator Carina Demman and explained the purpose for the visit. LPA conducted a tour of the physical plant with Carina, observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and residents' medications. The facility has an approved mitigation plan on file.

The facility is a one-story home located in a residential area. It is licensed to serve (6) elderly residents, ages 60 and above, of which all may be non-ambulatory, and is approved to retain (1) resident on hospice. The home consists of a living room, kitchen, dining room, TV room, (8) bedrooms, of which (2) are for staff, (4) bathrooms, of which (2) are for residents and (1) is for visitors, a shaded patio in the backyard with seating, and an attached garage. LPA observed all resident bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. LPA observed room# 2 to have baby powder spread underneath a resident bed and around the room floor, which made the floor slippery. Administrator stated caregivers clean once a week, but had not yet cleaned today. (2) resident bathrooms were observed to have a shower, toilet, and wash basin. The showers accommodate non-ambulatory clients and have the required grab-bars and non-skid mats. The water temperature was tested and measured between 118*F-120*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. The kitchen stove top had accumulated grease on the grills and burners as well underneath the microwave, which is located right above the stove, which poses a hazard for a grease fire. Fire extinguisher were observed throughout the facility to have current inspections and were fully charged. The first aid kit was inspected and had the required items, as well as a current first aid manual. All sharps were observed to be locked and inaccessible in a kitchen cabinet. Cleaning supplies were locked and inaccessible, stored in a cabinet underneath the kitchen sink. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit.
(Report continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2022
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 3


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: MONACO CREST GUEST HOME
FACILITY NUMBER: 197607612
VISIT DATE: 11/19/2022
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LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the kitchen and in the garage. Additional PPE was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with soap and paper towels.

All client files were reviewed and had updated emergency contact information and health screenings. (3) staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. All client medications were reviewed. They are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited in the LIC809-D.

An exit interview was conducted with administrator Carina and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/19/2022 05:08 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: MONACO CREST GUEST HOME
FACILITY NUMBER: 197607612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
87303 Maintenance and Operation
(a)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.(1)Floor surfaces… kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in the stove top, burners, grills, and underneath the microwave located above the stove to have accumulated grease that could cause a grease fire, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee will clean stove top, bruners, grills, and underneath the microwave to eliminate the accumulated grease. A picture of the cleaned items will be sent to LPA via email by the POC due date.
Type B
Section Cited
CCR
800787(a)
80087 Buildings 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
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Based on observation, interview, record review, the licensee did not comply with the section cited above in resident bedroom# 2 had baby powder all over the floor and near and under the resident's bed, making it slippery which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee will ensure to clean resident bedroom floor and take precautions to keep the powder off the floor. A picture of the clean floor and underneath the resident bed will be sent to LPA via email by the 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2022
LIC809 (FAS) - (06/04)
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