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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803671
Report Date: 07/20/2023
Date Signed: 07/25/2023 08:30:27 AM

Document Has Been Signed on 07/25/2023 08:30 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:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Administrator- CUNANAN, CARLOSTIME COMPLETED:
01:00 PM
NARRATIVE
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On 7/20/2023 at 8:05 a.m, Licensing Program Analyst (LPA) Ashley Calderon 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 closed off, 4 client bedrooms, two bathrooms, 1 staff room, a two-car attached garage, and a front & back yard.

LPA used CARE tool on todays inspection and toured the facility inside and out, reviewed food supply, 3 staff files/ 4 client files, 2 staff interviews and attempted 3 client interviews and reviewed 4 client medication(s) records.

Bedrooms 1-4 had furniture including bedframes, dressers, lamps, and chairs. Administrator is waiting on new night stands for each client. LPA was provided with receipt of order. Beds have the required linen and the linen is in good condition. Extra linen observed in hallway closet. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable, extra food in the garage. LPA observed sharps in locked cabinet. (Continuation on 9099-C)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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 4
Document Has Been Signed on 07/25/2023 08:30 AM - It Cannot Be Edited


Created By: Ashley Calderon On 07/20/2023 at 12:10 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: ROBILYN GUEST HOME II
FACILITY NUMBER: 197803671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client 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 client with self-administration, provided all of the following requirements are met: (B) 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
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Based on LPA observation, interview with Administrator and record review of medication log book and medication bubble pack that Client #1 pills remained and not provided to client on 7/19/23 for medication Quetiapine Tab 25mg , the licensee did not comply with the section cited above in 1 out of 5 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator immediately called pharmacy and asked how to proceed with medication that was not provided to client. Administrator was instructed by pharmacy to destroy medication and proceed to next date medication. Administrator will send in Special Incident Report to Licensing and to LPA on medication error. Administrator will provide medical professional training to staff who provide medications to clients and will provide LPA with training information and staff certification/ staff log by due date July 11,2023.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/25/2023 08:30 AM - It Cannot Be Edited


Created By: Ashley Calderon On 07/20/2023 at 12:10 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: ROBILYN GUEST HOME II
FACILITY NUMBER: 197803671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by LPA and Administrator observed 2 live roaches in bathroom #1 crawling on walls on/behind covid-19 posters, posted in bathroom wall and dead roaches on posters, the licensee did not comply with the section cited above in 4 out of 4 persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2023
Plan of Correction
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Administrator will get pest exterminator control to do treatment to get rid of roaches and will provide receipt and what services were provided.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


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: 07/20/2023
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Passageways and exits are free of obstruction. The front and backyard are well maintained. Back yard has shaded area, no large bodies of water observed. LPA observed 2 bathrooms, Bathrooms #1 near laundry was observed at 8:23am, LPA alongside with Carlos noticed 2 live crawling roaches and dead roaches on/ behind covid-19 posters, posted on bathroom wall,deficiencies were cited. Bathroom #1 had non-skid mats /grab bars. Bathroom #2 was clean and operable have grab bars and non-skid mats. Hot water temperature in both restrooms measured between Title 22 regulations. The facility temperature at the time of the visit was comfortable. Cleaning disinfectants , laundry supplies and cleaning solutions were locked in cabinets inaccessible to clients. There is sufficient lighting throughout the facility. Medications reviewed for all clients, medication book and medications were reviewed. Medications were locked in cabinet near dining table. LPA found a medication error for Client #1 (C1) bubble pack had Quetiapine Tab 25mg in packet and was not provided on 7-19-23 to C1, deficiencies were cited. Client files and Staff files reviewed and have required background and health screening documentation. Carbon Monoxide and smoke detectors were tested and in working order. Last disaster/fire drill conducted May 23, 2023. Administrator certificate expires on 10/28/2023.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Administrator, a copy of this report and Appeal Rights will be emailed to carlos.scunanan@yahoo.com. (LPA had printer issues)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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