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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801985
Report Date: 04/08/2024
Date Signed: 04/09/2024 08:54:09 AM

Document Has Been Signed on 04/09/2024 08:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVE N CARE GUEST HOMEFACILITY NUMBER:
197801985
ADMINISTRATOR/
DIRECTOR:		BRILLANTES, HARRYFACILITY TYPE:
735
ADDRESS:11866 E. 162ND. ST.TELEPHONE:
(562) 404-7601
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 8CENSUS: 7DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Luz BrillantesTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Luz Brillantes, Harry Brillantes and Irene smith and explained the purpose for todays visit. The facility phone number is 562 404 7601.

The facility consist of four resident bedrooms, one staff bedroom, three bathrooms(one located in staff area), a living room, dining room, kitchen, a patio with umbrella/table/chairs, backyard with storage shed, and an attached garage(office area, storage, additional food).

The facility had all postings at the front entrance, bathrooms, and throughout the facility.

LPA Wesley conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen/dining room area. The water temperature was tested and measuring 111.7 degrees F.

The following deficiencies were cited in accordance to the title 22 regulations. Appeal rights given. Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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Document Has Been Signed on 04/09/2024 08:54 AM - It Cannot Be Edited


Created By: Nicol Wesley On 04/08/2024 at 01:01 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: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 the LPA's observation, the licensee did not comply with the section cited above the facility needed a thorugh cleaning in the restroom, bathtubs, sinks, and overall cleaning in the inside cobb webs, wipe down, mop, and to remove the containers, bucket, ladders and debris from behind the storage unit which poses a potential health risk to the persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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The licensee will have the facility thoroughly cleaned and send proof of corrections(LIC 9098) to LPA Nicol Wesley by 05/06/24.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's observation, the licensee did not comply with the section cited above and had uncovered trash cans in the restrooms which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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The licensee shall replace the open trash cans with covered lids by poc date 04/22/24 and send proof by sending the LIC 9098 to LPA Nicol Wesley.
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:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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