198600256-9-22-2023-28-AS-CWOG-CVWPW4-20230922114008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600256
Report Date: 09/22/2023
Date Signed: 09/22/2023 11:40:55 AM

Document Has Been Signed on 09/22/2023 11:40 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HOME SWEET HOME		FACILITY NUMBER:	198600256
ADMINISTRATOR:	CODRUTA PAULA VALEANU		FACILITY TYPE:	740
ADDRESS:	3342 COLD PLAINS DR.		TELEPHONE:	(626) 333-4917
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	5	CENSUS: 3	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	CODRUTA PAULA VALEANU (Carol)		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required inspection and met with Administrator Codruta Paula Valeanu (Carol) who allowed the entry of the facility and explained the reason of the visit and assisted with the visit.. The facility is licensed to serve elderly residents age 60 and above. Fire clearance granted four (4) non-ambulatory and 1 bedridden. Facility may retain 3 hospice residents. The following twelve (12) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Staffing, Personal Records-Training, Resident Rights/Information, Resident Records/Incident Reports, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness and Resident with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice hand washing constantly. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: The facility is cleared for four (4) non-ambulatory and one (1) bedridden. Currently all the residents are non-ambulatory but no bed-ridden. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 3. Physical Plant and Environmental Safety: The facility is a two story house and located in a residential neighborhood area. First floor, its included living room, dining area, kitchen, three residents bedrooms and one resident bathrooms and attached garage. On the second floor, the administrator and families are living upstairs. LPA inspected all three residents bedrooms: Bedroom#1 and #2 has one bed, one closet, one drawer, one night stand, required furniture and beddings, sufficient lighting and closet space. Bedroom#3 has two beds, two night stands, two drawers, required furniture and beddings and sufficient closet space and lighting. The resident bathroom is clean, sanitary and in a good working condition. The bathroom also has required grab bar and non-skid mat. The hot water temperature tested in resident bathroom is 114.6 degrees F which is within the Title 22 regulation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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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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: HOME SWEET HOME	FACILITY NUMBER: 198600256
	VISIT DATE: 09/22/2023

NARRATIVE

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The appliances in the living room and kitchen are working well. The sharp knives and utensils are stored in the kitchen drawer and its locked and inaccessible to residents. The cleaning supplies are stored and locked in a cabinet on top of the washer and dryer in the garage The facility has a land line telephone system. LPA inspected the carbon monoxide detectors and its located in bedroom#3 and its working well. The walkway, passageway and patio are free of obstruction.

4. Staffing: The facility has sufficient staffing in the facility. All staff has updated CPR training. The administrator is living in the facility too, therefore she's always in the facility and she has a designated person when she's absent from the facility.

5. Personnel Record Training: All the staff files are stored and locked in the kitchen cabinet. The facility staff are all over 18 years old, associated with the facility and criminal background clearance. All staff does have the required training hours yearly. The facility administrator is Codruta Valeanu and her administrator certificate expiration date on 01/21/25.

6. Resident Records-Incident Reports: The resident files are stored and locked in the kitchen cabinet. LPA reviewed all three (3) resident files and they all have the required documents which included: face sheet, pre-placement appraisal information, appraisal/needs and service plan, admission agreement, updated physician report and TB test, ambulatory status and medication list.

7.Residents' Right : The facility has all the required posts including : Resident's right , non-discrimination notice, Licensing and Long Term Care Poster ..etc. The facility also has internet service shall provide at least one internet access device for resident use to face time with their families or entertainment.

8. Planned Activities: The facility does have sufficient space to accommodate both indoor and outdoor activities

9. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored probably. No residents are on modified diet that prescribed by the doctor.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HOME SWEET HOME	FACILITY NUMBER: 198600256
	VISIT DATE: 09/22/2023

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10. Incident Medical and Dental: The resident medication are centrally stored and locked in the kitchen cabinet. LPA inspected all three (3) residents medication and they all seemed accurate and updated. Each resident has the 30 day supply mediation. Administrator will also provide medical and dental transportation if needed.

11. Disaster Preparedness: The facility has an updated disaster plan dated on 09/22/23. The facility has two alternative temporary shelter location. The last fire/emergency drill was conducted on August 21, 2023.

12. Residents with Special Health Needs: Currently one (1) resident is on home health services for once a week. No resident is on hospice. No resident is under restricted health condition or prohibited health condition. Individual Service Plans and Appraisals are on file.

No deficiencies were observed during the visit

Exit Interview conducted and A copy of the report was provided to Administrator

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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