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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 09/03/2021
Date Signed: 09/03/2021 08:07:49 PM

Document Has Been Signed on 09/03/2021 08:07 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:BURTREE RESIDENTIAL FACILITYFACILITY NUMBER:
197803708
ADMINISTRATOR:LAMAUIG, JOYCELYNFACILITY TYPE:
735
ADDRESS:16422 BURTREE STREETTELEPHONE:
(626) 363-4162
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joycelyn Lamauig TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the administrator Joycelyn Lamuig and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and is approved on 05/02/21

The facility is a single story house located in residential neighborhood. The facility consists of three clients bedrooms, one client bathroom, one master bedroom with a bathroom for administrator and husband who live in the facility and one bedroom for administrator son also lives in the facility, dining area, living room and kitchen and a attached garage. While touring the garage, LPA observed there's an additional bedroom and bathroom there. According to the administrator, it has been built for only 7-8 months due to COVID-19. Administrator also reported that they never got any permit from the city or county or they never contacted Licensing or local department about the additional room. All clients' bedroom has two beds, closet, night stand and adequate lighting. Facility has sufficient linen supply including, mattress pads. The hot water temperature in the bathroom was measured at 125.1 degrees which is beyond the required 105 - 120 degrees. The food supply both perishable and non-perishable is sufficient. The common areas such as living room and dining area are clean and have the required furniture. The back yard has a shaded area and sitting area. The smoke detectors and carbon monoxide detectors are operational.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing between clients, disinfecting products are available in each room and facility is disinfected every 2 hours, restrooms have sufficient soap, paper towels, and signs, facility has an isolation room and PPE supplies are stored for 30 days.

Deficiencies cited on the 809 D. Exit interview conducted and copies provided to the administrator Joycelyn Lumauig
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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 09/03/2021 08:07 PM - It Cannot Be Edited


Created By: Christine Wong On 09/03/2021 at 12:34 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: BURTREE RESIDENTIAL FACILITY
FACILITY NUMBER: 197803708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(c)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview with administrator, the licensee did not comply with the section cited due to LPA observed there's an additonal bedroom and bathroom the garage which posed an potential risk to the clients
POC Due Date: 10/03/2021
Plan of Correction
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The adminsitrator will contact the City of La Puente immediately and see if the city allows garage converstions and if the city allows and approved and send the copy of the city permit to LPA by POC due date
Type B
Section Cited
CCR
80086(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited due to the administrator did not report to Licesning agency about the facility sketch changed about the additional bedroom and bathroom was built in the garage 7-8 months ago.
POC Due Date: 10/03/2021
Plan of Correction
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The administrator will ensure any changes for the facility plant which required to report to Liensing agency. The administrator will contact the City of La Puente immediately and request a permit and send us the udpated facility sketch and obtain fire clearances for the facility.
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/03/2021 08:07 PM - It Cannot Be Edited


Created By: Christine Wong On 09/03/2021 at 12:41 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: BURTREE RESIDENTIAL FACILITY
FACILITY NUMBER: 197803708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the sectionc cited due to the hot water temperature tested at the bathroom was 125.1 degrees F.
POC Due Date: 09/04/2021
Plan of Correction
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The administrator will adjust the hot water temperature immediately and will measure the hot water temperature daily and send the log to LPA by 09/10/21
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
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