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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800430
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:05:56 PM


Document Has Been Signed on 12/01/2022 04:05 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
GREATER LA AC/SC, 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:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Queen Alimario, caregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the infection control domain. Program Clinical Consultants (PCC) Toni Rivera and Anna Guinto were also present for the visit. LPA met with Caregiver, Queen Alimario, and explained the purpose for the visit.
The facility is approved for six (6) non-ambulatory adults, age 60 and over. There are currently 5 residents residing at the home.

A tour of the facility was conducted and the following were observed:
* There are 4 bedrooms (3 Client bedrooms and 1 vacant), 2 bathrooms, living room, dining area, kitchen, and an attached garage which is occupied by the live-in caregivers. There are no bodies of water at the premises.
* The facility has proper Coronavirus (COVID-19) signage inside the home but not at the front door. Hand washing signs are posted in each of the bathrooms and sink. However, LPA recommended to enlarge hand washing posters inside the bathrooms and to add signage at the front door.
* Upon arrival, LPA and PCCs did not observe Staff wearing face masks until it was requested. Staff took the temperature of visitors and documented on a log but did not properly screen for COVID-19 symptoms.
* Sufficient PPE supplies such as N95, surgical masks, and gloves are stored at the facility.
* Food supplies for 2 day perishable and a week of non-perishable were observed.
* Knives and sharps are stored and locked under a cabinet in the kitchen.
* Extra cleaning supplies and soaps are stored in the vacant client bedroom which is locked.
* Medications are centrally stored and locked.

LPA provided technical advisories for the following:
* clean/disinfect high touch surfaces at least once a day.
* enlarge poster inside the bathrooms and to add COVID-19 signage at the front door.
Deficiencies cited are provided on the LIC809D. An exit interview was conducted. A copy of this report, LIC809D, and appeal rights were given to Staff Alimario.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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 12/01/2022 04:05 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
GREATER LA AC/SC, 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: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(F)
87470 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 in which staff were observed not wearing their masks and did not conduct covid-19 screening which poses a potential health and safety risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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The licensee shall conduct an in-service training to staff regarding proper screening of visitors to include COVID-19 questionnaire and to ensure staff are wearing a mask when working with residents at the home. The training log shall be submitted to LPA by due date 12/8/22.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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