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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:27:10 PM

Document Has Been Signed on 09/06/2022 02:27 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:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Joycelyn Lamauig (Administrator)TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Joycelyn Lamauig (Administrator) and explained the purpose of the visit. The facility is licensed to serve: SIX AMBULATORY MENTALLY DISORDERED CLIENTS AGES 18 THROUGH 59.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, attached garage/office, 3 client bedrooms, 2 staff bedrooms and 2 bathrooms.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients. Lamps or lights in all rooms to ensure the comfort and safety were observed. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. LPA was allowed to enter the facility to conduct the inspection. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible. Hot water temperature measured at 128.3 degrees F in the hallway bathroom. Staff #1 and #2 who are responsible for direct care and supervision does not have current first aid.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Joycelyn Lamauig.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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Document Has Been Signed on 09/06/2022 02:27 PM - It Cannot Be Edited


Created By: Kruz Long On 09/06/2022 at 01:22 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: 09/06/2022

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


This requirement is not met as evidenced by: Hot water temperature measured at 128.3 degrees F in the hallway bathroom.
Deficient Practice Statement
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Based on observations], the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2022
Plan of Correction
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Water temperature was adjust at time of visit. Licensee shall maintain a water temperature log and provided a copy of the log to the department once hot water temperature measures between 105 degree F to 120 degree F.
Type A
Section Cited
CCR
80075(f)


This requirement is not met as evidenced by: Staff #1 and #2 who are responsible for direct care and supervision does not have current first aid.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee shall ensure that all staff responsible for direct care and supervision receive current first aid training and provide proof to the department.
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:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022


LIC809 (FAS) - (06/04)
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