197803708-8-24-2023-28-AS-KRAZ-CUZUXX-20230824155905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:59:16 PM

Document Has Been Signed on 08/24/2023 03:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BURTREE RESIDENTIAL FACILITY		FACILITY NUMBER:	197803708
ADMINISTRATOR:	LAMAUIG, JOYCELYN		FACILITY TYPE:	735
ADDRESS:	16422 BURTREE STREET		TELEPHONE:	(626) 363-4162
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 6		CENSUS: 6	DATE:	08/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Jocelyn Lamauig		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/24/2023 at 8:44 am. LPA was met by Licensee Jocelyn Lumauig explained the purpose of the visit. The facility is licensed serve developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:06 am and was led licensee. The facility is a single-story building located in a residential area with three (3) client bedrooms, two (2) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to six (6) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to six (6) out of six (6) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher nearby.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. All client bedrooms are shared. Client bedroom #3 closet door was off the rails and not properly functioning for its original intended use. LPA Ramirez will issue deficiency.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 08/24/2023 03:59 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 08/24/2023 at 12:09 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, client bathroom was observed to be dirty with hairs around toilet bowl, grime ring around tub, sink dirty smell of urine in bathroom, bathroom door has smeared stains, client bedroom closet door is broken, the licensee did not comply with the section cited above in 6 out of 6 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will clean and santize tub/shower, bathroom sink and toilet. Licensee will replace or repair client bedroom#3 closet door. Licensee will send photos of corrections via email by 9/7/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURTREE RESIDENTIAL FACILITY	FACILITY NUMBER: 197803708
	VISIT DATE: 08/24/2023

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Bathrooms: Water temperature in client bathroom#1 was measured at 105.7 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed door to have black smears, tub was observed with black grime ring around inside, sink was observe to be dirty and toilet contained hairs behind toilet seat. LPA Ramirez could smell a strong odor of urine near toilet.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in file cabinet located in kitchen area. Six (6) out of six (6) client medications were reviewed.

Backyard: No large bodies of water were observed.

Emergency Drills(Conducted every 6 months): Proof of last documented fire drill was conducted 1/15/23 at 10 am. Licensee had fire drill scheduled for 8/25/23. Licensee will send proof to LPA Ramirez by 8/25/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files were maintained at facility. LPA Ramirez reviewed two (2) staff files. Administrator certificate is currently being processed for renewal.

Client Files: Six (6) client files were reviewed. Admissions agreements, resident personal rights, and emergency contact information.

Infection Control Plan: Licensee will submit updated copy of Infection Control Plan to LPA Ramirez by 8/31/23 or LPA Ramirez may return to issue deficiency.

Deficiency is being cited. One (1) Technical Violation was issued during visit. Exit interview was conducted licensee and a copy of this report, 809-D, LIC 9102 TV, and appeals rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC809 (FAS) - (06/04)

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