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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802587
Report Date: 03/20/2023
Date Signed: 03/24/2023 01:54:17 PM

Document Has Been Signed on 03/24/2023 01:54 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:CULLEN HOMEFACILITY NUMBER:
197802587
ADMINISTRATOR:PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:14397 CULLEN STREETTELEPHONE:
(562) 696-9694
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 4DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Michelle Gozon-PunoTIME COMPLETED:
05:00 PM
NARRATIVE
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LPA Angelica Rea made an unannounced visit to Cullen Home. The purpose of today’s visit was to conduct the Required Inspection. On today’s visit LPA met with staff, Minerva Cobilla and Administrator, Michelle Gozon-Puno. The home has 4 consumers, all are ambulatory and none has a restricted health care condition. The facility conducted a fire drill on 3/6/23.

LPA Rea checked Client & Staff files, medications, staff fingerprint clearances, staff 1st aid certificates, consumer IPPs and inspected the home for hazards. During this visit, LPA inspected consumer bedrooms, 1 bathroom, living room, dining room and kitchen, and laundry area. The consumer bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Bedrooms had plenty of dresser and closet space observed. Walls and floors were in good condition. Hallways were clean, clear, and free of debris. Toilets and water facets worked properly. Water temperature measured 123.9 degrees F in the kitchen, and 126.1 degrees F in the bathroom. The fire extinguisher is fully charged and meets regulations.

Perishable food supply was checked and adequately stocked at time of visit. Smoke detectors were working properly, chemical compounds and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and in order. Outside grounds were toured and no bodies of water were observed.

Deficiencies cited on 809-D. Exit Interview, Copy of Report, and Appeal Rights given to Ms. Gozon-Puno.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 3
Document Has Been Signed on 03/24/2023 01:54 PM - It Cannot Be Edited


Created By: Angelica Rea On 03/22/2023 at 04:54 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: CULLEN HOME
FACILITY NUMBER: 197802587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 hot water measured at 123.9 in the kitchen, and 126.1 in the resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/24/2023 01:54 PM - It Cannot Be Edited


Created By: Angelica Rea On 03/22/2023 at 04:54 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: CULLEN HOME
FACILITY NUMBER: 197802587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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. LPA observed a large amount of clutter in the shaded patio area designated for clients. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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4
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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3