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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:43:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/04/2024 03:43 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:
03/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Adelaida AsuncionTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced case management - annual continuation visit. LPA met with Adelaida Asuncion (Administrator) and explained the reason for the visit. The initial annual visit was conducted on 01/23/24.

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 room, one (1) room for family member; three (3) bathrooms, kitchen, dining room, living room, and detached garage.
During the visit, the CARE tool was used, facility was toured, staff/residents files were reviewed. Residents medications were reviewed.
No pools and bodies of water on the premises. All residents' bedrooms and bathrooms were inspected.
Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was tested in all bathrooms,and reading shows 100.4 degree F. Adequate linen and personal hygiene supplies was observed. Auditory alarm devices to monitor exits were operable. Last fire drill was conducted on 12/10/23. Sufficient supply of perishable and nonperishable foods is observed. There is additional food in the refrigerators located in the garage. Knives and sharps are locked in the kitchen and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguisher observed in the dining room and fully charged. Laundry area was observed in the covered patio between the house and garage. Laundry detergents were observed unlocked next to the washer and dryer.
The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet; resident and staff records are stored in a locked room and both inaccessible to residents. First Aid kit was fully stocked with current manual. LPA reviewed 3 residents' medications. R1's Folic Acid 1 mg and Aspirin EC 81 MG were present at the facility / prescribed by the doctor, but not listed / recorded on the MAR.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Adelaida Asuncion.



SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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Document Has Been Signed on 03/04/2024 03:43 PM - It Cannot Be Edited

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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2024
Section Cited
CCR
87303(e)(2)

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 Water supplies and plumbing fixtures shall be maintined 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 lee than 105 (degrees F (41 degree C) and not more than 120 degrees F (49 degree C).
This requirement is not met as evidenced by:
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Water temperature was adjusted at the time of visit.
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Based on observation, the licensee did not comply with the section cited above. In all bathrooms water temperature is at 100.4 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/04/2024
Section Cited
CCR87309(a)

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 Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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 Laundry detergents were locked at the time of visit.
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Based on observation the licensee did not comply with the section cited above. Laundry detergents were observed unlocked next to washer and dryer, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/04/2024 03:43 PM - It Cannot Be Edited

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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
87465(a)(5)

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Incidental Medical and Dental Care.
(a) A plan for incidental medical and dental care shall be developed by each facility...
(5) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidence by:
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At the time of visit R1's medications added / recorded in the MAR. Licensee / administrator will ensure medication provided to the residents is recorded properly by staff on medication sheet. Licensee will conduct a medication in- service training and will provide a copy of the materials and the Sign in sheet before POC due date.
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Based on observation administrator did not ensure that R1's medications are listed in the MAR. R1's Folic Acid 1 mg and Aspirin EC 81 MG were present at the facility / prescribed by the doctor, but not listed / recorded on the MAR.
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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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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