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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600155
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:54:41 PM

Document Has Been Signed on 12/01/2022 02:54 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:SOUTHERN CALIFORNIA ASSISTED LIVINGFACILITY NUMBER:
198600155
ADMINISTRATOR:RYAN MAGNOFACILITY TYPE:
735
ADDRESS:1510 EDANRUTH AVENUETELEPHONE:
(626) 813-2552
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 6CENSUS: DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Facility Manager Leilani TelebricoTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Facility Manager Leilani Telebrico and explained the reason for the visit. The facility is approved for six (6) ambulatory developmentally disabled adults, ages 18-59. There are currently six (6) clients residing in this facility and receive case management services provided by San Gabriel/Pomona Regional Center. Physical Plant was toured, medication records, staff files, and food supply were inspected. The facility is a single-story residence located on residential street. The facility has an open front yard and enclosed backyard with an attached patio cover. During the tour, LPA observed a living room area, kitchen, dinning room area, stock room, four (4) client bedrooms, one (1) client bathroom, one (1) staff office, one (1) staff bathroom, and attached garage.

LPA observed construction debris including glass, sink, bricks, and a folding table located on the side facility walkway. Bedrooms #1, #2, #3, #4 contained a bed, linen, dresser, chair, light and sufficient closet space. LPA observed all mattresses in bedrooms #1, #2, #3, #4 to not contain the required mattress pad, plastic or rubber sheeting. Client bathroom contained non-skid mat and was observed to be stocked with soap and hand sanitizer. Due to clients stuffing paper towels in the toilet, staff keeps paper towels stocked near the bathroom. LPA tested the water in client bathroom at 129 F degrees which is higher than the required 105F – 120F degrees. LPA observed a 3x4 square cemented tile gap in the middle of the bathroom floor. Per Facility Manager Telebrico, the facility is being remodeled and the bathroom floor is scheduled to be repaired. Smoke detectors were observed throughout the facility and were tested. LPA observed a carbon monoxide detector located near entry of the home. There is a fire extinguisher located in the kitchen which is fully charged. LPA observed sharps to be locked in the stock room which is inaccessible to clients. Cleaning supplies and toxins are locked in the stock room which is inaccessible to clients. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable and 7-day non-perishable foods were observed. Six (6) out of the (6) client medications were reviewed. Medications are centrally stored in a locked cabinet located in the living room. Medications are documented and given as prescribed. LPA viewed 4 staff files.

Deficiencies are being cited. See LIC 809D.


Exit interview was conducted with Facility Manager Leilani Telebrico . A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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 5
Document Has Been Signed on 12/01/2022 02:54 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/01/2022 at 12:20 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: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, contruction debris including glass, sink, bricks, and a folding table located on the side facility walkway, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Adminitrator/Licensee will submit picture proof that debris was removed.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, mattresses in client bedrooms did not contain the required mattress pads; rubber or plastic sheeting, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Administrator/Licensee will submit receipts for mattress pads, or rubber or plastic sheeting.
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: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/01/2022 02:54 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/01/2022 at 12:21 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: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

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


This requirement is not met as evidenced by: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Deficient Practice Statement
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Based on observation, LPA measured water tempertaure in client bathroom which read at 129F degrees,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Administrator/Licensee will ensure water temperature meets Title 22 Regulations at all times. Facility staff adjusted and lowered water temperature during today's visit. Administrator/Licensee to monitor water temperature for the next 24 hours and submit water log to LPA by the end of 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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/01/2022 02:54 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/01/2022 at 01:28 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: SOUTHERN CALIFORNIA ASSISTED LIVING
FACILITY NUMBER: 198600155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
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.
Deficient Practice Statement
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Based on observation, client bathroom contained a 3x4 cemented gap that was missing tile flooring, the licensee did not comply with the section cited above, in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Administrator/Licensee will submit photo proof of tile flooring repaired
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
Page: 5 of 5