197607853-12-19-2023-28-AS-JBAE-CYNSKQ-20231219125706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607853
Report Date: 12/19/2023
Date Signed: 12/19/2023 12:57:17 PM

Document Has Been Signed on 12/19/2023 12:57 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:	JENNAE CREST		FACILITY NUMBER:	197607853
ADMINISTRATOR:	ERWIN JUN S. DE GUZMAN		FACILITY TYPE:	740
ADDRESS:	19302 CHAMBLEE AVENUE		TELEPHONE:	(562) 331-8880
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 4	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Administrator		TIME COMPLETED:	01:00 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	On 12/19/23 at 8:21 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Jennae Crest. Upon arrival LPA was greeted by Direct Support Professional (DSP) Malou Bonifacio who contacted the Administrator, Erwin De Guzman. At 9:18 a.m. the Administrator arrived and LPA explained the reason for the visit. The licensee prefers to serve clients age 60 and over. Four (4) ambulatory and two (2) non- ambulatory only. There were four (4) residents in care during the time of this visit. LPA was unable to observe physical copy of administrator certificate. The administrator stated renewal was mailed during the year 2022. LPA was unable to locate administrator’s name on CCLD website for Active or Pending administrator certificates. 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, (4) resident files, medications, and medication administration records for (4) residents. This home contains 4 bedrooms, 2 bathrooms, living room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 132.1F-145.1F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. Toxins and cleaning supplies was observed unsecured by bathroom toilet. Toilet tank cover was missing and currently being covered by cardboard and resident pad. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was in the hallway, tested, and functioning properly. There were (1) fire extinguisher located in kitchen 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. LPA observed knife left unattended in the kitchen. 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. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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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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: 12/19/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 hot water temperature measured at 132.1 through 145.1, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	The administrator will lower the water heater to maintain complaince and send log/picture to LPA by POC due date.

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(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 receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, intervew, and record review, the licensee did not comply with the section cited above in which the facility has 3 non ambulatory and 1 ambulatory. The facility has an approved fire clearence for 2 non ambulatory poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Licensee / Administrator will apply for a new fire clearance to increase number of ambuatory capacity for resdients in care. Licensee/ Administrator will submit all the documenation needed to process the change of capacity to LPA.

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 Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
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: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 in which the toliet tank cover and the button to flush is not working, poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	The administrator will ensure the facility is in good repair and send photo proof to LPA by POC due.

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 in which LPA observed cleaning solutions and toxins unsecured in the bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	The facility will secure all toxins and send photo 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 Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
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: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 the administrator and S2 did not have TB records in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/26/2023
	Plan of Correction
1 2 3 4	The administrator will send a copy of TB test 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 Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
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: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87406(a)

Administrator Certification Requirements

(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. 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 in which there is currently no active administrator certifcate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	The administrator will submit proof of administrator certificate to LPA by POC due date.

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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/19/2023 12:57 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: JENNAE CREST	FACILITY NUMBER: 197607853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of person with Dementia (f) the following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other itemsthat could constitute a danger to the residents. 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 in which LPA observed a knife on kitchen counter, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The facility secured the knife during the visit. The administrator will conduct in-service training inregards to care of person with dementia and send proof by POC due date.

Type A

Section Cited

CCR

87465(a)(6)

Incidental, Medical and dental care (6) When requested by prescribing physcian or the department, a record of dosage of medications which are centrally stored shall be maintained in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, R1 was missing physicans orders, R2 medication record is based on dischared paperwork dated 2/18/2022, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	The administrator will ensure all medical documents are in the facility and placed within the residents files 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 Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JENNAE CREST	FACILITY NUMBER: 197607853
	VISIT DATE: 12/19/2023

NARRATIVE

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Medications Had no Medication administration records. Resident # R1 did not have physician’s orders and LPA could not review R1’s medication. LPA reviewed R2 medications with discharge paperwork dated 2/18/2022. There was no sufficient information that shows the medications was given as prescribed. Per LIC 602’s and observation the facility has 1 Ambulatory and 3 non ambulatory which is not in compliance with fire clearance requirements.

Staff files was incomplete. The administrator and S2 did not have proof of TB screening in file. S2 only had Live scan documents in file.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The living room a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6 and civil penalties assessed. Exit interview conducted with Erwin De Guzman, Administrator, a copy of this report was provided, and Appeal rights given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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