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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:51:13 PM


Document Has Been Signed on 01/26/2023 03:51 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: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:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Rosemarie A Honrado, administratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Rosemarie A Honrado, administrator, who assisted with the visit and spoke with Adelaida Asuncion, Licensee over the phone. The facility is licensed to serve Dementia residents, ages 60 and above, approved for two (2) non-ambulatory and four (4) ambulatory residents. The facility is a single-story house located in a residential neighborhood. It consists of five (5) bedrooms including three (3) resident bedrooms, one (1) staff, one (1) room for family member; three (3) bathrooms, kitchen, dining room, living room, and a one (1) car detached garage. The facility has an approved Hospice Waiver for two (2) residents. Currently, there is no hospice resident in placement. Administrator certificate is current with expiration date on 04/08/24.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, staff and residents files were reviewed, staff and residents were interviewed, and medications were reviewed.



LPA toured the facilities, indoor and outdoor. Residents’ bedrooms were furnished with appropriate furniture for residents’ comfort. Bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 115.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. (- continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASUNCION BOARD & CARE
FACILITY NUMBER: 198600290
VISIT DATE: 01/26/2023
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Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space was available allowing residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke and carbon monoxide detectors are dual, not hardwired and operable. Fire extinguishers’ last service is 03/17/2022 and are fully charged.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

No deficiencies were cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Rosemarie. Administrator’s signature on this form confirmed receipt of these documents. A copy of LIC 809 report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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