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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803708
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:21:48 PM

Document Has Been Signed on 07/30/2024 03:21 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/
DIRECTOR:		LAMAUIG, JOYCELYNFACILITY TYPE:
735
ADDRESS:16422 BURTREE STREETTELEPHONE:
(626) 363-4162
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee Joycelyn LamauigTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Annual Required Visit for the facility. LPA was met by Licensee Joycelyn Lamauig explained the purpose of the visit. The facility is licensed serve (6) ambulatory, mentally disordered clients 18-59 years old. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today.
The following domains were completed:
Infection Control: Staff are using appropriate hand hygiene and wearing gloves when deemed necessary. Facility has an Infection Control Plan in place. LPA to collect a copy.

Operational Requirements: The fire clearance is approved for up to (6) ambulatory clients. Staff are adhering to operational requirements. Sufficient outdoor space for client use was observed.

Physical Plant & Environment Safety: The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, attached garage. Bedroom have required furniture for clients in care. There are no pools or bodies of water on the premises. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature measured within Title 22 regulations of 105-120 degrees.

Staffing: There is sufficient staffing at the facility. Administrator certificate for Joycelyn expires on 5/17/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed two (2) staff files and they have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Fingerprint clearances were observed.
Continued on 809-C page
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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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: BURTREE RESIDENTIAL FACILITY
FACILITY NUMBER: 197803708
VISIT DATE: 07/30/2024
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Client Rights-Information: Clients are informed of their personal rights. No postural support devices are being used.

Client Records-Incident Reports: LPA reviewed all four (4) Client files, maintained at the facility. They have the required documentation such as Admission Agreements, Physician's Report (including T.B and Ambulatory Status), Emergency and Identification Sheet, Consent forms, Appraisal/Needs and Services Plans, Client Rights, Property Valuable and Cash resources forms.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in bubbled packs. LPA reviewed medications for all four (4) Clients. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. LPA observed medications for the following day to be already popped out into cups. Citation is being provided.

Incidental Medical Services: There are (0) clients with restricted health condition plan.

Disaster Preparedness: The facility has the current Emergency Disaster Plan in place. Facility advised to update to new LIC 610. Last emergency drill was conducted on 4/17/24.

Emergency Intervention: There is no use of manual restraints at this facility.

Per Title 22 Regulations, a deficiency is being issued today. Please see attached LIC 809-D

An exit interview was conducted. Appeal Rights discussed. A copy of this report and appeal rights were provided to the administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 03:21 PM - It Cannot Be Edited


Created By: Jose Villalobos On 07/30/2024 at 02:53 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: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (4) of (4) Client mediations observed were popped out into medicince cups a day in advance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Administrator to review Title 22 Section 80075 and provide LPA with a letter of proof it was completed by POC due date.
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:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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