<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803655
Report Date: 08/09/2024
Date Signed: 08/14/2024 08:14:28 AM


Document Has Been Signed on 08/14/2024 08:14 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:HOME OF PERPETUAL CAREFACILITY NUMBER:
197803655
ADMINISTRATOR:LEAH ANGELA IGNACIOFACILITY TYPE:
740
ADDRESS:3027 WENWOOD ST.TELEPHONE:
(909) 392-3482
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Caregiver Stephanie MarianoTIME COMPLETED:
12:50 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) Christian Gutierrez conducted an unannounced Annual Required Visit at approximately 8:07 AM. LPA was met by Care giver Stephanie Mariano and explained the purpose of the visit. Administrator Leah Ignacio arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one zero (0) can be on hospice. It was observed that facility has one resident receiving hospice care without a waiver from department. Deficiency has been cited.The facility is a single-story home, located in a residential area. The home consists of a living room, (3) residents’ bedrooms, (1) live-in staff room, (1) room designated for licensee with (1) full bathroom inside the room, (1) resident bathroom, a kitchen, pantry, dining room, living room, detached garage, and shaded patio with seating in the backyard.
LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. Bedroom one (B1) is a shared room and it was observed to have a camera on dresser of resident (R2). Bedroom four (B4) was observed to have full bed rails without physicians’ orders. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguisher which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients in kitchen pantry. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. It was observed that facility did not have a sufficient supply of 2 days perishable & 7 days non-perishable food deficiency cited. Sharps are locked and placed in cabinet in kitchen. During tour of facility, it was observed that resident R1 was walking around unsupervised with scissors. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. LPA observed a hospital bed and mattress against wall next to shaded patio deficiency cited. The garage is clean and has extra supplies.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 7


Document Has Been Signed on 08/14/2024 08:14 AM - It Cannot Be Edited

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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above the facility did not have suffcient supply of 2 day perishable food and 7 day non perishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Administartor will provide proof of receipt and pictures to LPA via email that food was bought.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above scissors where accessible to residents and R1 was walking around with them during visit with no supervision which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Administartor will conduct training to all staff to insure all sharps are locked and inaccessible to residents and send proof of training to LPA.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 08/14/2024 08:14 AM - It Cannot Be Edited

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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(b)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one (1) out of three(3) shared bedrooms resident R2 and R3 had a camera in room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Administartor will take out camera and go over residents personal rights and send LPA proof that training was conducted.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above residents medication was observd in refrigerator not locked in seprate box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Administartor will buy a lock box and send LPA pictures as proof.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 08/14/2024 08:14 AM - It Cannot Be Edited

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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents did not have medication that was ordered by physcian at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Gabapentin 30 mg 1 cap 2x a day, Citalopran 10 mg 1 tablet a day,and Melatonin ! tablet at bedtime a day will be ordered and proof will be sent via email to LPA.
Type A
Section Cited
CCR
87633(a)(1)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents are on hospice care and facility did not obtain a waiver which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2024
Plan of Correction
1
2
3
4
Administartor will submit documents and request waiver to department for R3.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 08/14/2024 08:14 AM - It Cannot Be Edited

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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above LPA observed hospital bed and mattress outside in back yard against wall where shaded patio is at which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
Administrator will clear backyard area and send picture via email as proof to LPA.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility did not have any records of any drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
Administrator will conduct drills withh all staff and send a copy of drills via email to LPA. Administartor agrees to conduct and record drill quarterly.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 08/14/2024 08:14 AM - It Cannot Be Edited

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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of five residents did not have a physician order for full bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
Administartor will obtain a physcians order for bed rails and send proof via email to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655
VISIT DATE: 08/09/2024
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
26
27
28
29
30
31
32
Three (3) Staff files were reviewed and included Criminal clearance record, CPR/training was missing for S3, and health screening with TB. Administrator certificate pending. Five (5) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was not conducted deficiency cited. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen it was observed that facility had medication in refrigerator not locked in separate box deficiency cited. LPA reviewed medications for all clients and the following was observed R2 was missing Gabapentin 300mg, Citalopram 10 mg, and Melatonin deficiency cited.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator Leah Ignacio.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7