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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607954
Report Date: 07/22/2023
Date Signed: 07/22/2023 05:24:00 PM


Document Has Been Signed on 07/22/2023 05:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:DHANIELLA'S CARE HOMEFACILITY NUMBER:
197607954
ADMINISTRATOR:CIPRIANA L. ANCHETAFACILITY TYPE:
740
ADDRESS:1380 OAKHORNE DRIVETELEPHONE:
(310) 534-0187
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 4DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Pia Luistro TIME COMPLETED:
04:31 PM
NARRATIVE
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On 07/22/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with caregiver Pia Luistro and Reyner Navarro. LPA explained the purpose of today’s visit. Cipriana Ancheta the administrator was unavailable to be present for the visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. Currently, the facility has (1) hospice resident in care. The facility is approved for (6) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (2) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 109.8 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained.
(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954
VISIT DATE: 07/22/2023
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas.

An audit of residents #1-#4 (R1-R4) service files and staff #1-#4 (S1-S4) personnel files. The facility has the current administrator's certification on file for Cipriana Ancheta #6010956740 Exp 03/01/24.

Deficiencies:
  • Observation of cleaning solution/powder bleach in bathroom #2.
  • Observation of full bed rails for room # 4 Residents #1 and #2 and did not a physicians approval.
  • Observation of a hole in the ceiling inside an upper kitchen cabinet.
  • Observation of Resident's medications in prep cups sitting on top of cabinet accessible to residents in care.
  • No proof of certification of Liability Insurance.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

Due to time constraints, interviews were not conducted with resident and staff.

An exit interview was conducted with Pia Luistro and a copy of the report was provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/22/2023 05:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA identified a hole in the ceiling inside the cabinet that needs to be repaired. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2023
Plan of Correction
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Licensee will ensure to provide a safe, clean and sanitary accomodations for residents. A repair of the ceiling hole must be completed by POC due 08/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 07/22/2023 05:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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
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Based on (observation), the licensee did not comply with the section cited above. LPA observed cleaning solution/powder bleach under the sink in room bathroom #2. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2023
Plan of Correction
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Licensee will ensure that all hazardous chemicals are stored in a locked storage not accessible to residents in care. Proof of correction must be sent by POC 07/23/23.
Type A
Section Cited
CCR
87309(b)
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in
(a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above. LPA observed all resident's medications in prep cups sitting on a cabinet exposed and accessible to residents in care. This violaion which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2023
Plan of Correction
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Licensee will review and retrained staff to ensure that all medications are stored in locked storage and not asccesible to residents in care. Proof of correciton must be sent by POC 07/23/23.
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 07/22/2023 05:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(1)
(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft
ties, used to achieve proper body position and balance, to improve a resident's mobility and
independent functioning, or to position rather than restrict movement including, but not limited to,
preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (record review)], the licensee did not comply with the section cited above. LPA observed resident #1 & #2 had full bed rails and did have authorized doctor's prescription. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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Licensee will ensure to remove full bed rails and review Title 22 Reg 87608. Proof of correction must be sent by due date 07/28/23.
Type B
Section Cited
HSC
1569.605


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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/22/2023 05:24 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
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 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 is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above. The facility currently does not have proof of liability insurance. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2023
Plan of Correction
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LIcensee will ensure to obtain liabity insurance coverage to meet the requirements of HSC 1569.605. Proof of correction must be sent by 08/05/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6