197607831-10-18-2024-28-AS-CGUZ-DA6NXC-20241018105055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607831
Report Date: 10/18/2024
Date Signed: 10/18/2024 10:51:04 AM

Document Has Been Signed on 10/18/2024 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MAUNA LOA OAKS "LLC"		FACILITY NUMBER:	197607831
ADMINISTRATOR:	LIUBOV SHEVTSOVA		FACILITY TYPE:	740
ADDRESS:	19041 E. MAUNA LOA AVE.		TELEPHONE:	(626) 387-9186
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 3	DATE:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Liubov Shevtsova Administrator		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Administrator Liubov Shevtsova at approximately 8:15 AM and explained reason for visit.

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 toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be accessible to clients in cabinet next to dining room deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The shower accommodates non-ambulatory residents and has the required grab-bars and non-skid mat. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies.

SEE LIC 809C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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 10/18/2024 10:51 AM - 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAUNA LOA OAKS "LLC"	FACILITY NUMBER: 197607831
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 one (1) bottle gallon of elmers glue one (1) bottle purex liquid starch left in unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Administrator removed solutions at time of visit and will conduct training and send to LPA by email.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAUNA LOA OAKS "LLC"	FACILITY NUMBER: 197607831
	VISIT DATE: 10/18/2024

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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Three (3) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted in April 2024 TV was given. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian Gutierrez	TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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