197801456-3-11-2025-28-AS-DKOI-DENQ6Z-20250311115423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801456
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:54:34 AM

Document Has Been Signed on 03/11/2025 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	FILIPINAS CARE HOME		FACILITY NUMBER:	197801456
ADMINISTRATOR/ DIRECTOR:	CORPUZ, DANIEL		FACILITY TYPE:	735
ADDRESS:	18422 SEADLER DR		TELEPHONE:	(626) 789-7157
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	03/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Mercedes Corpuz, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced Annual Inspection and met with Administrator Mercedes Corpuz who allowed the entry of the facility and explained the reason of today's visit. 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 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. 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. 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. Toilets and faucets are in working condition. The hot water temperature tested in the client's bathroom was 111.2 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. Clean linens, towels, blankets, and pillows are stored in the hallway closet.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FILIPINAS CARE HOME	FACILITY NUMBER: 197801456
	VISIT DATE: 03/11/2025

NARRATIVE

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Physical Plant and Environmental Safety [Cont.]: 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. Fire extinguishers are in the kitchen and is fully charged and last inspected on 04/10/2024.

Operational Requirements: Facility Administrator is adhering to operational requirements. 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:

Staffing: The facility has three (3) staff in the facility. The NOC shift staff has the required planned emergency procedure training.

Personal Records/Staff Training: All the staff files are stored in the file cabinets. LPA reviewed five staff files which are over 18 years old with background check cleared and associated with the facility. LPA inspected all three (3) staff files and they all have the required documents in files which includes: personnel record, health screening, TB Test result and required training hours. The administrator is Mercedes Corpuz and administrator certification expiration date on 4/7/25. The administrator has an updated HIV and TB training certificate in file.

Client's Rights: The facility has no clients requiring any postural supports. The facility also provides internet access and telephone access.

Food Service: The facility has a sufficient supply of two days perishable and seven days non-perishable food supply in the facility. The kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. No clients are on modified diet with doctor's prescription. All the food in the facility are stored properly.

Client Records and Incident Reports: All the client's files are stored in the cabinet near the dining area. LPA reviewed Client files for Client #1 (C1) through Client #4 (C4). Client files are maintained at the facility and have the following documents in their files - Face sheet, Updated Medical Assessment-Physical Exam (including T.B and Ambulatory Status), Immunization records, Individual Program Plan (IPP), Functional Capabilities Assessment, Centralized Stored Medication Destruction Record, and Clients Personal Rights. LPA also reviewed the Clients’ P & I.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FILIPINAS CARE HOME	FACILITY NUMBER: 197801456
	VISIT DATE: 03/11/2025

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Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items. Facility staff provide transportation to medical and dental appointments.

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.

Disaster preparedness: The facility have an updated emergency disaster plan (LIC610D) in file. The last fire/disaster drill was conducted on 12/05/2024. The facility has two temporary alternative shelter location.

Emergency Intervention: The facility is not using any restraints on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code,there were no deficiencies observed during the visit. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator, Mercedes Corpuz.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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