<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600488
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:45:07 AM

Document Has Been Signed on 02/13/2024 11:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PUNZALAN HOME VFACILITY NUMBER:
198600488
ADMINISTRATOR:PUNZALAN, ED & ERLINDAFACILITY TYPE:
735
ADDRESS:13314 ASHWORTH PL.TELEPHONE:
(562) 404-2899
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 3DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Adminsitrator Erlinda PunzalanTIME COMPLETED:
12:01 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
On 2/13/24 at 8:36 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Punzalan Home V. LPA visited the wrong address and observed the facility address states Place, but the home is on Street. Upon arrival there was no one at home and LPA contacted the Administrator, Erlinda Punzalan. Care staff arrived at 9:35 and the administrator arrived shortly after. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (1) non-Ambulatory and (3) Ambulatory Adults ages 18 through 59. The facility is a level 4G home and the vendor is Harbor Regional Center. There were no clients in care during the time of this visit, all the clients were at their day program. The last emergency disaster/fire drill was conducted on 12/5/2023. The Administrator Certificate expires on 12/02/2024 #6021344735. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 2 bathrooms, living room, office, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and skid mats. The temperature measured at 126.1*F-130.1*F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 3
Document Has Been Signed on 02/13/2024 11:45 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 02/13/2024 at 11:24 AM
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: PUNZALAN HOME V
FACILITY NUMBER: 198600488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA inspections with Administrator, the water temperature measured at 126.1*F and ;130.1*F in bathroom #1, and #2. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
1
2
3
4
Licensee/Administrator agrees to turn down the water heater and have a water temperature tested and record on a log three times per day over the next two days and submit as proof of correction to CCLD by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PUNZALAN HOME V
FACILITY NUMBER: 198600488
VISIT DATE: 02/13/2024
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
26
27
28
29
30
31
32
The outdoor grounds were toured and inspected, and the patio was well maintained with exercise machines and a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The dining room contained playing cards, board games and activity supplies available to the clients. In addition, a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

The office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6. Civil penalties assessed. Exit interview conducted with Erlinda Punzalan, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3