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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600522
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:21:27 PM

Document Has Been Signed on 04/25/2023 05:21 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:PKD GROUP HOMEFACILITY NUMBER:
198600522
ADMINISTRATOR:NANONG, PRISCILLA T.FACILITY TYPE:
735
ADDRESS:1127 NO. BARRANCA AVENUETELEPHONE:
(626) 332-0815
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 6DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lilian Salmorin, Staff in chargeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met Lilian Salmorin, staff, who assist with the visit. The facility is licensed to serve six (6) Developmentally Disabled Adult clients (ages 18-59), ambulatory only. Currently, there are six (6) clients in placement. LPA discussed with staff regarding the purpose of today's visit and the inspection.

During the visit, the Care tool was used, a tour of the facility was conducted, food supply was reviewed, staff/clients files were reviewed and medications were reviewed.

The facility is a single family home located in a residential neighborhood. Facility consists of three (3) bedrooms, staff room, office, two (2) bathrooms, living room, dining room, kitchen, laundry area, garage and an indoor/outdoor activity area. Client rooms are furnished with appropriate furniture for clients’ comfort. Bathrooms are operational and furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the clients. A shaded area with chairs is provided in the back yard. The yard is free of debris/ hazard, and there are covered trash cans provided. Sufficient supply of perishable and nonperishable foods is observed.

Smoke detectors and carbon monoxide detector are operable and in compliance. Fire extinguishers are fully charged. The first aid kit is fully stocked. Hot water temperature measured at 117.7 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed. The last Fire/ Emergency Drill was conducted on 3/20/23. Medications are centrally stored, locked and the records are current. Hazardous items are locked and inaccessible to clients. Annual licensing fees are current. Administrator certificate is current with expiration date on 3/2/24.

(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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: PKD GROUP HOME
FACILITY NUMBER: 198600522
VISIT DATE: 04/25/2023
NARRATIVE
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Deficiencies were observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with staff Lilian, who’s signature on this form confirm receipt of these documents. A copy of LIC 809 report and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 05:21 PM - It Cannot Be Edited


Created By: Bonnie Tao On 04/25/2023 at 04:57 PM
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: PKD GROUP HOME
FACILITY NUMBER: 198600522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
Deficient Practice Statement
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A junk car, number plate “2VMT904” was park at the side yard.
A dishwasher is missing under the kitchen counter in which there is an empty space/hole under the kitchen counter.
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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Licensee agreed to remove the junk car from the side yard and agreed to purchase a new dishwasher to install in that place in the kitchen by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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