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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800430
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:00:34 PM


Document Has Been Signed on 11/28/2023 01:00 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: 4DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Queen Alimario-CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/28/2023. LPA was met by Caregiver Queen Alimario and explained the purpose of the visit. The facility is licensed to serve six (6) non ambulatory residents over the age of 60.

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of four (4) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) residents in care. Kitchen sink water temperature was measured at 117.3 degree F. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed several boxes stacked on top of each other in kitchen area.

Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed several boxes stacked on top of each other in various corners/areas of living room.

Linen Closet: Contained plenty linens, towels, and hygiene products.



see 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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 9


Document Has Been Signed on 11/28/2023 01:00 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: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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, several boxes containing various items were seen stacked throughout the facility,the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee will removed boxes and store in location other than common areas. Must send picture proof by 12/12/23.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, original signed and dated admissions agreement was not in resident file,the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee will place original signed and dated admissions agreement in resident file. Must provide picture proof by 12/12/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 11/28/2023 01:00 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: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no documented drills were observed,the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee will conduct drills and document according to title 22. Must send proof by 12/12/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9


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
VISIT DATE: 11/28/2023
NARRATIVE
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Resident Rooms 1 - 4: LPA Ramirez inspected four (4) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. Bedroom#1 is shared, bedroom#2 is currently unoccupied, and bedroom# 3 and #4 are shared.

Bathrooms: Water temperature in bathrooms# 1-2 were within 105-120 degree F.

Backyard: No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: Staff could not provide documented proof if emergency drills conducted.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for four (4) staff. Documented proof of required annual training was not observed.

Resident Files: Four (4) resident files were reviewed. Original signed admissions agreements were not observed in resident files.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9