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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803671
Report Date: 06/20/2022
Date Signed: 06/20/2022 11:21:39 AM

Document Has Been Signed on 06/20/2022 11:21 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:ROBILYN GUEST HOME IIFACILITY NUMBER:
197803671
ADMINISTRATOR:REYNOLDS, ERLINDAFACILITY TYPE:
735
ADDRESS:16332 ALORA AVENUETELEPHONE:
(562) 916-7728
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Carlos CunananTIME COMPLETED:
11:36 AM
NARRATIVE
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On 6/20/222 at 9:05 a.m, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting a required annual inspection. On today's visit LPA met with Administrator, Carlos Cunanan who assisted with the visit.

The home is vendorized through the Harbor Regional Center (HRC) and the South-Central Los Angeles Regional Center and is designated as a Level 4N home. Facility is licensed to served 4 developmentally disabled adults between the age of 18 and 59 years old of which 2 shall be non-ambulatory.

The facility consists of a single-story structure that contains a living room, dining room, kitchen, laundry room, backroom with fireplace, 4 client bedrooms, two bathrooms, a two-car attached garage, a front & backyard.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, staff files, and resident medications.

Report Continued on 809 C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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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: ROBILYN GUEST HOME II
FACILITY NUMBER: 197803671
VISIT DATE: 06/20/2022
NARRATIVE
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Bedrooms 1-4 have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. LPA observed knife in kitchen sink. Staff 1 (S1) removed and locked knife in locked cabinet during the visit. Passageways and exits are free of obstruction. The front and backyard are well maintained. Back/Front yard do not have shaded area. Administrator confirmed they will get another Umbrella. Licensee purchased shaded area during the visit and administrator provided a copy of the receipt to LPA. Bathrooms 1-2 are clean and have infection control signs. The hot water temperature measured at 111.3 – 105.4 degrees F. for bathrooms 1-2. The facility temperature at the time of the visit was comfortable. There is sufficient lighting throughout the facility. Medications reviewed for all residents and it appears to be given as prescribed. Staff files reviewed and have required background and health screening. Infection control signs posted throughout the facility and LPA observed 30 days’ supply of PPE’s located in the garage. Carbon Monoxide and smoke detectors tested in working order. Last disaster drill conducted December 5th, 2021. Administrator certificate # 6004040735 expire 10/28/2023.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with licensee / Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/20/2022 11:21 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 06/20/2022 at 10:57 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: ROBILYN GUEST HOME II
FACILITY NUMBER: 197803671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022

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 because LPA observed knife in kitchen sink upon arrival, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
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Cleared during visit. Staff 1 moved all sharps to a locked cabinet during the visit. Administrator to send a letter to licensing that the Licensee has read & will comply with section 80087(g) by POC due date.
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:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/20/2022 11:21 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 06/20/2022 at 10:57 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: ROBILYN GUEST HOME II
FACILITY NUMBER: 197803671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in which LPA observed no shaded area in the back or front yard. Adminstrator confirmed removal of umbrella in line to purchase a bigger shaded area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Cleared during the visit. Administrator will send photo proof or reciept of purchase of new shaded area by POC due date. Licensee purchased shaded area during the visit and administrator provided a copy of the receipt to LPA.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022


LIC809 (FAS) - (06/04)
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