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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802587
Report Date: 10/25/2024
Date Signed: 10/25/2024 12:36:32 PM

Document Has Been Signed on 10/25/2024 12:36 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/
DIRECTOR:		PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:14397 CULLEN STREETTELEPHONE:
(562) 696-9694
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Josephine Cochongco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced site visit. The purpose of the visit is to follow-up on Regional Center Semi-Annual Residential Review recommendations. LPA met with staff Minerva Cobilla. New Administrator Josephine Cochongco and back-up Administrator arrived shortly after. LPA conducted file review and a physical plant inspection.

Observations:

1. All four (4) residents at the facility are over the age of 59. There are no Age Exceptions of file. A citation was issued.

2. Bedroom # 2 has a sliding door with a locking mechanism that is in not working/locking the door. A citation was issued.

3. LPA was not allowed entry into staff bedrooms 4 & 5. The door was locked and live-in staff & Administrator did not have a key. Per Title 80044(a)(2) " Any authorized employee of the licensing agency may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice." Citation was issued.

4. Administrator on record is not current. Staff showed proof that on 3/6/2024 change of Administrator documents were mailed to to former LPM Patricia Magana. Staff were instructed to resubmit documents to Regional office to LPM Lisa Hicks.


On 4/30/2024, Eastern Los Angeles Regional Center, Quality Assurance & Compliance Specialist, Kristine Cheung issued recommendations of items listed below:
    Appropriate medical treatment is provided promptly to resident. [Includes appointments with specialists,
    i.e. gynecology, neurology, etc....Recommendation: Follow up and or schedule doctor appointments for the individuals to ensure all medical needs are being conducted and seen by the doctors.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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: CULLEN HOME
FACILITY NUMBER: 197802587
VISIT DATE: 10/25/2024
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continuation of 4/30/2024 Semi-Annual Residential Review conducted by, Eastern Los Angeles Regional Center, Quality Assurance & Compliance Specialist, Kristine Cheung.
    P & I monies records are accurate and current. No receipts were accounted for 2 residents. Recommendation: Maintain accurate P & I records.

    Residents attend and participate in community and recreational opportunities. (minimum one (1) time per
    week). Recommendation: Monthly Activities Calendar and Monthly Menu with a disclaimer of a discussion with the individuals to ensure or attempt they understand their options.

    Staff are familiar with IPP/Treatment Plan objectives. Recommendation: Licensee shall provide a refresher training to all staff to be familiar with the individual ISP/IPP goals/objectives to support his/her needs in daily routines.

    Client Notes are kept current and include, community and leisure activities, overnight visits, medical and dental appointments, special incidents, etc. Recommendation: Staff demonstrated attempts in including more details aligned with HCBS requirements. However, daily notes did not include each shift summary and how staff support the IPP goals/objectives for the individuals.

    Staff have knowledge of legal reporting requirements. Staff was unable to indicate the appropriate reporting requirements. ELARC recommended a refresher training for all staff.

    *Plan of Operation and Staffing update needed to include live-in staff changes. Recommendation: Submit to CCL and ELARC an Addendum to the Plan of Operation, facility sketch, and maintain staff training documentation. NOTE: Per revised (12/4/2006) Program Design, it states that the facility will be operated by a live-in direct care staff. There are currently 3 live-in staff residing

Per, physical plant inspection and record review Licensee submitted to ELARC corrections to all above items on dates 5/2/24, 5/8/24, and/or 5/31/24.

Exit interview was conducted with Josephine Cochongco. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 12:36 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/25/2024 at 11:31 AM
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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
85068.4(g)

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Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients.... the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
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Administrator/Licensee shall submit Age Exception requests for R1 -R4 by POC due date, and/or submit written plan to relocate residents. A list of required documents was emailed to Administrator.
*If an extension is required submit a written request by the due date.
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Based on record review, all 4 residents are over the age of 59. Their ages are [77, 66, 63, 61]. No age exceptions are on file. This poses a potential health and safety risk to persons in care.
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Type B
11/22/2024
Section Cited
CCR80087(a)

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Building and Grounds. 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:
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Administrator stated that it was repaired in May 2024, but it is not working again. Licensee has not been able to find the part in need of repair. LPA recommended that until the locking mechanism is repaired and/or replaced, staff shall install an auditory alarm in order to alert staff.
Submit picture proof of repairs.
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Based on physical plant inspection, bedroom # 2's sliding door's locking mechanism is not working/locking the door. This poses a potential health and safety risk to persons in care.
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


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Document Has Been Signed on 10/25/2024 12:36 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/25/2024 at 11:57 AM
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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2024
Section Cited
CCR
80044(a)(2)

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Inspection Authority of the Licensing Agency
Inspection Authority. Any authorized employee of the licensing agency may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice.
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Licensee shall train all staff in regulation 80044.
1. Submit a written plan that addresses access to live-in staff bedrooms, and contigency plan when keys are lost.
2. Proof of staff in-service training.

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This requirement was not met evidenced by:
During physical plant tour, staff did not provide access to live-in staff bedrooms 4 & 5. Live-in staff and Administrator stated they do not have a key. This poses a potential health and safety risk to persons in care.
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


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