<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320054
Report Date: 02/01/2023
Date Signed: 04/27/2023 07:35:10 AM

Document Has Been Signed on 04/27/2023 07:35 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LOMITA TERRACE GUEST HOMEFACILITY NUMBER:
198320054
ADMINISTRATOR:T.BUCA, JERISSA MARIEFACILITY TYPE:
740
ADDRESS:1711 W 243RD STTELEPHONE:
(408) 916-7347
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 4DATE:
02/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Robin TaporcoTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/01/23 at 10:30 am a non-compliance conference meeting was held for this facility Licensee Robin Taporco, Jerelyn Taporco, Jerissa Buca of Lomita Terrace Guest Home, Regional Manager (RM) Benita Yates, Licensing Program Manager (LPM) Janae Hammond and Licensing Program Analysts (LPAs) Ernand Dabuet and Lizeth Villegas were all present at this meeting. LPA Dabuet explained additional deficiencies associated with forfeiture of license.

The licensee is cited for failure to adhere to Title 22 regulations for the following:

· 87405 Administrator’s Qualifications and Duties
· 87109 Transferability of License
· 87112 Conditions for Forfeiture of a License
· 87224 Eviction Procedures

The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

Based on interviews and observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8

Deficiencies are issued and an exit interview is conducted with Robin Taporco. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 04/27/2023 07:35 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/01/2023 at 12:47 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LOMITA TERRACE GUEST HOME
FACILITY NUMBER: 198320054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
87405(b)(2)

1
2
3
4
5
6
7
87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 ) Knowledge of and ability to conform to the applicable laws, rules and regulations.
1
2
3
4
5
6
7
The licensee will create a written plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 02/15/23
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on interview and record review the Licensee failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/15/2023
Section Cited
CCR87109(a)(b)

1
2
3
4
5
6
7
87109 Transferability of License
(a) The license shall not be transferable.
(b) The licensee shall notify the licensing agency and all residents receiving services, or their representatives...
1
2
3
4
5
6
7
The licensee will create a written plan to ensure that the administrator reviews regulation 87109 Plan of correction will be submitted by POC due date: 02/15/23
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on interview and record review the Licensee failed to notifiy CCLD and resident of forfeiture of license. This violation which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/27/2023 07:35 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/01/2023 at 12:55 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LOMITA TERRACE GUEST HOME
FACILITY NUMBER: 198320054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
87112(1)(A)

1
2
3
4
5
6
7
(1) "Licensee abandons the facility" shall mean either of the following: (A) The licensee informs the licensing agency that the licensee no longer accepts responsibility for the facility, or
1
2
3
4
5
6
7
The licensee will create a written plan to ensure to have reviewed 87112 regulations and signed and date. Plan of correction will be submitted by POC due date: 02/15/23
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on interview and record review the Licensee failed to adhere to Title 22 regulations improper eviction process and abondoned residents. This violation which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/15/2023
Section Cited
CCR87224(A)(1)(2)(A-F)

1
2
3
4
5
6
7
(5) Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. 1.In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use...
1
2
3
4
5
6
7
The licensee will create a written plan to ensure to have reviewed 87224 regulations and signed and date.. Plan of correction will be submitted by POC due date: 02/15/23
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on interview and record review the Licensee failed to adhere to Title 22 regulations resulting to improper eviction. This violation poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3