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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:08:24 PM

Document Has Been Signed on 08/17/2022 03:08 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:
08/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Joycelyn Lumauig – AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted a case management visit after discovering deficiencies during a complaint investigation for control number: 28-AS-20220811150320. Client 1 (C1) has his medication unlocked in his room. C1 shares his room with another client. The administrator has the other 5 clients' medication locked. C1 states he is able to self-administer his own medication, but there is no physician report for C1 in his file to determine if C1 is able to self administer his own medication.

The deficiencies cited are documented on the LIC809D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 2
Document Has Been Signed on 08/17/2022 03:08 PM - It Cannot Be Edited


Created By: Luis Mora On 08/17/2022 at 02:17 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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2022
Section Cited
CCR
80075(k)(1)

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80075 - Health Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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.
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At the time of this visit, administrator confiscated all the medication and locked it with the other centrally stored medications, making it inaccessible to clients.

Deficiency was cleared at the time of visit and no further action is needed.
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This requirement is not met as evidenced by:

LPA observed all of C1's medication that was unlocked in C1's room.
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Type B
08/26/2022
Section Cited
CCR80069(b)(1)

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80069 - Client Medical Assessment
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional.....
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Administrator will submit a copy of C1 physician's report to the department by POC due date 08/26/22.
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This requirement is not met as evidenced by:

C1 did not have a physician report on file.
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2