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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607831
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:30:42 PM

Document Has Been Signed on 11/29/2022 02:30 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:MAUNA LOA OAKS "LLC"FACILITY NUMBER:
197607831
ADMINISTRATOR:LIUBOV SHEVTSOVAFACILITY TYPE:
740
ADDRESS:19041 E. MAUNA LOA AVE.TELEPHONE:
(626) 387-9186
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 2DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Liubov Shevtsova- AdministratorTIME COMPLETED:
02:45 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) 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 Liubov Shevtsova and explained the purpose for the visit. LPA conducted a tour of the physical plant with administrator, observed the food supplies, COVID-19 procedures, and reviewed resident and staff files, and resident's 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 over, of which (5) may be non-ambulatory, (1) may be bedridden, and has a hospice waiver approved for (3). The home consists of a living room, kitchen, dining room, (4) resident bedrooms, (2) resident bathrooms, (1) staff bedroom, 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. (1) bathroom was observed to have a shower, toilet, and wash basin and the other was equipped with a toilet and wash basin. The shower accommodates non-ambulatory residents and has the required grab-bars and non-skid mat. The water temperature was tested and measured between 115*F-118*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. A fire extinguishers was observed in the kitchen and in the garage to have current inspections and were fully charged. All sharps were observed to be locked and inaccessible in a cabinet in the kitchen next to the stove. Cleaning supplies were locked and inaccessible, stored in a cabinet in the garage. Extra linens were observed in a closet in the garage and were in good condition. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. All equipment was operational and in good repair.


(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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 2
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: MAUNA LOA OAKS "LLC"
FACILITY NUMBER: 197607831
VISIT DATE: 11/29/2022
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
LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored throughout the home. Additional PPE was observed at the entrance of the facility. 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 liquid soap and paper towels.

(2) of (2) client files were reviewed and had updated emergency contact information and health screenings. (2) 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, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with administrator and a copy of this report and Technical Advisories were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2