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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801985
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:02:48 PM

Document Has Been Signed on 03/06/2023 04:02 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVE N CARE GUEST HOMEFACILITY NUMBER:
197801985
ADMINISTRATOR:BRILLANTES, HARRYFACILITY TYPE:
735
ADDRESS:11866 E. 162ND. ST.TELEPHONE:
(562) 404-7601
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 8CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Luz Brillantes, StaffTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Harry Brillantes and staff Luz Brillantes. There are five (5) ambulatory mentally disabled adults ages 18-59.

The following 12 (CARE) tool domains were utilized during the inspection: 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 and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station in the dining room. Room #1 is designated as a COVID-19 isolation room if needed. A COVID-19 Mitigation Plan was reviewed. However, Licensee has not submitted an Infection Control Plan.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for eight (8) ambulatory mentally disabled clients. It consists of 4 client bedrooms, 1 live-in staff bedroom, living room, dining room,, kitchen, 3 bathrooms, backyard with patio area, and an attached garage.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. Kitchen sink reading was 126 D'F, bathrooms were 127 and 125.2 degrees Fahrenheit.
  • Rooms #1- #4 have exit doors to the exterior physical plant with door frames that are not sized accurately. A discarded wood planks, pillows, and tables was observed in right rear area of the backyard.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LOVE N CARE GUEST HOME
FACILITY NUMBER: 197801985
VISIT DATE: 03/06/2023
NARRATIVE
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Operational Requirements:
  • Care and supervision to meet the clients needs was observed.
  • The last fire inspection clearance was conducted on Nov. 14, 2019 by the LA County Fire Department.
  • Surety bond of $1,000.00 is current.

Staffing:
  • A total of 4 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 1/12/2023. Proof that recertification training was submitted to CCL was provided.
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Proof of staff training was not observed in files. All staff had expired 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders, personal rights are on file.

Client Records/Incident Reports:
  • Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Appraisal/ Needs and Services Plans, TB clearance, Functional Capability Assessment, Psychiatric Evaluations, personal rig, medical consent, medication records, and P & I records were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Physician orders for modified diets are on file.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
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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: LOVE N CARE GUEST HOME
FACILITY NUMBER: 197801985
VISIT DATE: 03/06/2023
NARRATIVE
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Five (5) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medication Administration Records were disorganized.
  • Medications are given according to Physician directions.

Incident Medical and Dental:
  • Clients do not have prohibited health conditions or restricted health care plans. No hospice waiver is in place.

Disaster Preparedness, and Emergency Intervention:
  • Emergency Disaster Plan LIC 610D containing emergency evacuation, storage and preservation of medications, operation of manual assist devices was posted.
  • The facility shall conduct a drill at least quarterly for each shift. The last fire/emergency drill was conducted on 2/3/2023.

  • Facility has a First Aid Kit and Manual.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview conducted with Luz Brillantes. A copy of the report and appeal rights were emailed due to printing problem.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/06/2023 04:02 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/06/2023 at 02:21 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: LOVE N CARE GUEST HOME
FACILITY NUMBER: 197801985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that kitchen knives were observed unlocked in the garage cabinet in which clients have access; this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2023
Plan of Correction
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Administrator agreed to submit by tomorrow a written statement of how it was corrected.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 that the water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. Kitchen sink reading was 126 D'F, bathrooms were 127 and 125.2 degrees Fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2023
Plan of Correction
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Administrator agreed to submit a hot water temperature log with water temperature readings tested 3 times today and tomorrow. POC due tomorrow.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/06/2023 04:02 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/06/2023 at 02:21 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: LOVE N CARE GUEST HOME
FACILITY NUMBER: 197801985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
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 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Licensee has not submitted an Infection Control Plan; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Administrator agreed to submit an Infection Control Plan (ICP) by POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 that rooms #1- #4 have exit doors to the exterior physical plant with door frames that are not sized accurately, and the backyard right rear area has discarded wood planks, pillows, and tables; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Administrator agreed to submit proof of corrections/pictures by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/06/2023 04:02 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/06/2023 at 02:21 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: LOVE N CARE GUEST HOME
FACILITY NUMBER: 197801985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 none of the client beds had mattress pads; they only had mattress protectors; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Administrator agreed to submit proof that mattress pads were purchased and placed in all client beds.
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that proof of current required staff trainings (1st Aid/CPR) was not provided and stated that the documents may be at licensee's home; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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Administrator shall submit a written statement/self certification addressing the deficiency, and how it was corrected. Submit proof of staff 1st Aid/CPR training, and a list of all the training topics that have been updated by all staff.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023


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