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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801456
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:18:56 PM

Document Has Been Signed on 03/05/2024 02:18 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:FILIPINAS CARE HOMEFACILITY NUMBER:
197801456
ADMINISTRATOR:CORPUZ, DANIELFACILITY TYPE:
735
ADDRESS:18422 SEADLER DRTELEPHONE:
(626) 789-7157
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Daniel Corpuz TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Christine Wongi conducted the unannounced Annual Inspection and met with Administrator Daniel Corpuz and Mercedes Corpuz who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59 and ambulatory only. The facility is vendorized as Level 4A home with San Gabriel Pomona Regional Center.

The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel records-training, client rights- information, client records-incident reports, food service, health related services, incidental medical services, disaster preparedness and emergency intervention.

1. Infection Control Plan: The facility staff continue to practice hand washing and using gloves in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan in place

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, kitchen, dining area, three clients bedrooms, one client bathroom and one live in staff room and an attached garage. Each client bedrooms have two beds, chair, two dressers, required furniture and beddings and sufficient lighting and closet space. The client's bathroom is clean, sanitary and in a good working condition. The hot water temperature tested in the client's bathroom was 106.1 degrees F which is within the Tittle 22 regulation. All the appliances in the kitchen are working properly. The sharp knives are locked and stored in the kitchen drawer. The cleaning supplies are stored and locked in the cabinet in the garage. The extra personal hygiene products are stored in the garage cabinet. The hallway light is always on during night for client to access the non-private bathroom. The facility has a telephone service on the premises. LPA inspected the carbon monoxide detectors in the facility and they are working well. The passageway, walkway and patio are free of obstruction.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FILIPINAS CARE HOME
FACILITY NUMBER: 197801456
VISIT DATE: 03/05/2024
NARRATIVE
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3. Operational Requirements: All the clients in the facility are ambulatory which is within the fire inspection requirement. The last fire drill was conducted on 2/1/24. The facility has a shaded area with table and chairs for client to utilize the outdoor activity. The facility would let the client to attend or participate the community activities if there's a chance or opportunity:

4. Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the required planned emergency procedure training.

5. Personal Records/Training: All the staff files are stored in the cabinet near the dining area. All the staff have the required documents including health screening, TB Test result and required training hours. Administrator's first aid certificate expired on Oct, 2023. The administrator is Daniel Corpuz and administrator certification expiration date on 4/6/25. The administrator has an updated HIV and TB training certificate in file.
6. Client's right: No client in the facility required any postural support. The facility also provided at least one internet access device and equipped with video conferencing for client to access.

7. Food Service: The facility has ample supply of two days perishable and seven days non-perishable food supply in the facility. No clients are on modified diet with doctor's prescription. All the food in the facility are stored properly.

8. Client Records and Incident Reports: All the client's files are stored in the cabinet near the dining area. All the client files have all the required documents which include: Face sheet, admission agreement, updated Physician report, Individual Program Plan (IPP), medication list, ambulatory status and functional capacity assessment.

9. Health Related Services: All the clients' medication are centrally stored and locked in the kitchen cabinet and LPA inspected all four clients' medication. One of the C1's medication (Trazodone 10omg) was popped for tonight (3/5/24) bed time. All clients have the 30 days supply of medication.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FILIPINAS CARE HOME
FACILITY NUMBER: 197801456
VISIT DATE: 03/05/2024
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10. Incidental Medical Services: No client in the facility are on any restricted health condition plan or required high level of care. The facility is not retaining any client with prohibited health condition.

11. Disaster preparedness: The facility has an emergency disaster plan but it's not updated. The last one was completed on 03/10/21. The facility has two temporary alternative shelter location.

12. Emergency Intervention: The facility is not using any restraints on clients but all staff are CPI trained.


Deficiencies are being cited under the California Code of Regulations Title 22 Division 6 Chapter 1 and will be noted on 809-D page.

An exit interview is conducted, copy of the report and appeal rights given was provided to the administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 03/05/2024 02:18 PM - It Cannot Be Edited


Created By: Christine Wong On 03/05/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FILIPINAS CARE HOME
FACILITY NUMBER: 197801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed C1's tonight (3/5/24) bedtime medication (Trazodone 100mg) was popped which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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The administrator will ensure the medication was given according to physician's direction. The administrator will retrain the staff and send the staff training log to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/05/2024 02:18 PM - It Cannot Be Edited


Created By: Christine Wong On 03/05/2024 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FILIPINAS CARE HOME
FACILITY NUMBER: 197801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, LPA observed S1 and S2 did not have an updated First Aid training certfiicate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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The adminsitrator will send the updated First Aid training certificate by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6