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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800430
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:39:15 PM

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:OASIS OF LOVE PLAZA CAREFACILITY NUMBER:
197800430
ADMINISTRATOR:LAURA IGNACIOFACILITY TYPE:
740
ADDRESS:2993 BAYBERRY COURTTELEPHONE:
(909) 392-5914
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 5DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Caregiver, Queen AlimarioTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Queen Alimario and explained the reason for the visit. The Administrator was unavailable for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 116.2 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. There is a carbon monoxide detector in the hallway. The backyard has a shaded area and sitting area. The facility does not have any cameras inside or outside the home.

LPA reviewed all resident files. Files were observed to be complete and had updated emergency contact information. LPA reviewed staff files. Files were complete including but not limited to first aid certificates, health screenings, proof of training, and proof of fingerprint clearance. LPA reviewed all residents' medications. Medications are documented properly and given as prescribed. At the time that LPA entered the facility, staff did not assess or take LPA's temperature. Also LPA was not required to sign-in. The assessment of visitors and sign-in policy are required per COVID-19 procedures and per approved mitigation plan.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to caregiver.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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: OASIS OF LOVE PLAZA CARE
FACILITY NUMBER: 197800430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation made, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. A sign-in policy is required for all visitors to ensure compliance with central entry point for symptom screening and to record contact information. This practice has a health and safety impact that includes, but is not limited to personal rights, and reporting requirements.
POC Due Date: 12/10/2021
Plan of Correction
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Facility staff will be trained on sign-in procedures. Proof of training will be submitted by 12/10/21.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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