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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 02/02/2022
Date Signed: 02/02/2022 12:49:59 PM

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:ASUNCION BOARD & CAREFACILITY NUMBER:
198600290
ADMINISTRATOR:ROSEMARIE A. ZIMMERFACILITY TYPE:
740
ADDRESS:1636 S. RAMA DRIVETELEPHONE:
(626) 338-0772
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY:6CENSUS: 4DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Adelaida Asuncion; LicenseeTIME COMPLETED:
01:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Licensee Adelaida Asuncion and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Ms. Asuncion toured the home and inspected (4) resident bedrooms, (1) staff bedroom, (3) bathrooms, living room, dining room, kitchen, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the back patio. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and measured between 101.7F - 101.8F which is below the required 105F - 120F degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the hallway of the home. There is a fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked in the garage and are inaccessible to residents. First Aid kit was fully stocked with current manual. Staff were observed checking visitors temperature at the time of entry.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (4) out of the (4) resident medications were reviewed. Medications are centrally stored in a cabinet located in the kitchen. LPA observed Resident #1 had Vitamin D3 and Calcium D3 medications but were not labeled. LPA also observed Resident #2 had Aspirin medication which was not labeled.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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 2
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: ASUNCION BOARD & CARE
FACILITY NUMBER: 198600290
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
(h) The following requirements shall apply to medications which are centrally stored:

(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During medication review, LPA observed Resident #1 had Vitamin D3 and Calcium D3 medications which were not labeled. LPA also observed Resident #2 had "Kirkland" Aspirin which was not labeled. This poses a potential health, safety, and/or personal rights risk to the residents in care.
POC Due Date: 02/16/2022
Plan of Correction
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Administrator/Licensee to contact R1's and R2's Physicians to obtain written orders and labels for these medications by POC due date.
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows:

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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During Physical Plant tour, LPA measured water temperature in bathroom #1 and bathroom #2 and water temperature measured between 101.7F - 101.8F which is below the required 105F - 120F.
POC Due Date: 02/09/2022
Plan of Correction
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Administrator/Licensee to ensure water temperature meets Title 22 Regulations. Licensee adjusted water temperature at the time of the visit. *POC Cleared*.
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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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