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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607853
Report Date: 08/01/2024
Date Signed: 08/01/2024 11:54:10 AM


Document Has Been Signed on 08/01/2024 11:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:JENNAE CRESTFACILITY NUMBER:
197607853
ADMINISTRATOR:ERWIN JUN S. DE GUZMANFACILITY TYPE:
740
ADDRESS:19302 CHAMBLEE AVENUETELEPHONE:
(562) 331-8880
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 3DATE:
08/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:DSP Marilou BonifacioTIME COMPLETED:
12:10 PM
NARRATIVE
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On 8/01/2024 at 10:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a POC visit to Jennae Crest. Upon arrival LPA met with Direct Support Professional Marilou Bonifacio, who contacted the Administrator Erwin De Guzman. LPA Baptiste spoke to the Administrator via phone and explained the reason for the visit.

During the phone conversation with the Administrator, LPA Baptiste explained to the administrator the three (3) residents currently at the facility are all non-ambulatory. The facilities fire clearance is approved for two (2) non-ambulatory only. LPA further explained the facility cannot admit non- ambulatory residents because they are currently over the limit per there fire clearance. The facility Administrator confirmed they understood and stated the resident has nowhere to go. LPA discussed Liability insurance and the Administrator confirmed they are still in the process of getting insurance for both facilities and has spoken to an underwriter. LPA also discussed not receiving a copy of the facilities plan of operation and the Administrator stated they need 2 days because it was misplaced. LPA discussed the infection control plan to which the Administrator stated they will send a copy of it today. Regarding, the updated physician report for 1 resident diagnosed with Dementia, the Administrator stated the family has not completed the document and will remind them today. LPA also discussed not receiving documents needed to complete an open investigation: control # 28-AS-20240705103218. The Administrator stated the documents will be sent as soon as possible. Failure to correct the Plan of Correction will result in further actions.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6. Civil penalties assessed. Exit interview conducted with Direct Support Professional Marilou Bonifacio. 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: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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 08/01/2024 11:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: JENNAE CREST
FACILITY NUMBER: 197607853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
HSC
1569.605

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Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three
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Licensee shall submit proof of liability insurance or evidence by POC due date
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million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement has not been met as evidenced by the Department's request for licensee to provide proof of liability insurance per 1569.605 by 7/29/2024
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Type B
08/14/2024
Section Cited
CCR87204(a)

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87204(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may recieve services at any one time. A exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
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The licencee will relocate 1 non ambulatory resident. Proof of relocation will be sumbitted to LPA by POC due date
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This requirement is not met as evidence by:
Based on observations and record review, the licensee did not comply with the section cited above. 3 residents in care are non-ambulatory and the facility is approved for 2 only, which poses an immediate health, safety or personal rights risk to persons in care.
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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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2024 11:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: JENNAE CREST
FACILITY NUMBER: 197607853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
CCR
87705(c)(5)

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(5)Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement was not met as evidence by:
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The Administrator will ensure all residents with dementia has update physicans report/ medical assessments annually. The Administrator will update Residents R2 and R3 physcians report and send a copy to LPA by POC due date.
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Based on observation and file review, the licensee did not comply with the section cited above in which 2 residents with dementia do not have updated physicans report, which poses a potiential health, safety or personal rights risk to persons in care
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Type B
08/15/2024
Section Cited
CCR87470(c)

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(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
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The administrator will submit an infection control plan to LPA by POC due date.
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Based on record review, the facility never submit the infection control plan or does not have an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 08/01/2024 11:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: JENNAE CREST
FACILITY NUMBER: 197607853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87506(d)

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87506(d) Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours......

This requirement was not met by evidence of:
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Licensee and Administrator shall provide all resident records upon request to Community Care Licensing. Administrator agreed to provide the documents via email to LPA.

Submit all documents by POC due date.
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 LPA requested documents pertaining to complaint control # 28-AS-20240705103218. A list of documents needed was given during the initial visit. As of the time of this report the documents had not been received. Administrator stated the documents will be sent as soon as possible.
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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: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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