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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600579
Report Date: 12/09/2022
Date Signed: 12/12/2022 03:49:20 PM

Document Has Been Signed on 12/12/2022 03:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CENTURION RESIDENTIAL CAREFACILITY NUMBER:
198600579
ADMINISTRATOR:PORTER, FRANCES PORTERFACILITY TYPE:
735
ADDRESS:303 ARDILLA AVE.TELEPHONE:
(626) 369-9185
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Angelia PorterTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA Kimberly Ramirez conducted an unannounced Required 1-year annual visit utilizing the Infection Control Tool. LPA meet with DSP II Mary Jo Donato and explained the reason for the visit, Administrator Angela Porter arrived shortly after. Physical plant was toured, medications records were reviewed, and food supply was reviewed. There are four (4) level 4g developmentally disabled clients in the home; of which 2 can be non-ambulatory. There are currently two (2) clients under the age of 59 years old and two (2) clients over the age of 60 years old. The facility is a single-story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, living room, dining area, office area, shaded patio, and car port. The last emergency disaster drill was conducted on 06/19/2022.

Observations:

· COVID-19 Infection Control signs were observed in the entrance and bathrooms. Screening protocols are in place. Clients in care do not wear a mask because it is not tolerated due to cognitive impairment.


· Each client bedroom is designated as a COVID-19 isolation room if needed.
· Four (4) centrally stored client medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked closet.

· Sharps and chemicals/cleaning supplies are stored and inaccessible to clients.

· Smoke detectors were tested and are operational. Fire extinguishers are fully charged. The facility has a fire pull alarm system.

· Facility has sufficient PPE’s except for gloves. PPE’s are being stored in living room area. Administrator will move to a different location that clients do not have regular access.

· Water temperature in kitchen was measured at 116.6 degrees F which is in the required 105-120 degrees F.

CONT 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CENTURION RESIDENTIAL CARE
FACILITY NUMBER: 198600579
VISIT DATE: 12/09/2022
NARRATIVE
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· Cabinet door in kitchen is missing, several cabinet doors are missing knobs, side wall near stove and stove vent has food spatter and grease.

· Insufficient supply of staple nonperishable food for a minimum of one week and fresh perishable foods for a minimum of two days was observed.Refrigerator was observed to be dirty and have food spillage inside.

· Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon monoxide detector in the hallway of the home was tested and operable. There is a fire extinguisher located in the kitchen which is fully charged. Sharp objects were observed to be locked in a cabinet and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet located in office area.

· Bathroom #1 water temperature was measure at 114.4 degrees F which is in the required 105-120 degrees F. Bathroom #1 sink is being held up by a shower curtain rod. Bathroom #2 water temperature was measured at 118.2 degrees F which is in the required 105 – 120 degrees F.

· Trimming/moldings on doorways and throughout the facility are broken and missing.

· Backyard has excessive leaf matter.

· Wall in living room area has several holes and wallpaper is torn in different areas.

· Construction to Bedroom #4 wall was being conducted. Per Administrator Porter, a door and ramp/wheelchair access is being constructed. Neither the department nor San Gabriel Valley/Pomona Regional Center was not notified before construction or alterations were made.

Deficiencies are being cited. See LIC 809D.


Exit interview was conducted with Administrator Angela Porter. A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 12/12/2022 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/09/2022 at 12:48 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: CENTURION RESIDENTIAL CARE
FACILITY NUMBER: 198600579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation,cabinet door in kitchen is missing, several cabinet doors are missing knobs, side wall near stove and stove vent has food spatter and grease, trimming/moldings on doorways and throughout the facility are broken and missing,wall in living room area has several holes and wallpaper is torn in different areas, refrigerator was observed to be dirty and have food spillage inside, PPE’s are being stored in living room area the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator/Licensee will fix cabinet/ door knobs, clean and sanitize stove wall and vent, replace and fix moldings/trimming, patch holes in walls and fix wallpaper or paint walls, clean and sanitize the refrigerator, move PPE's from living room area and store in area not of regular use by clients.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, backyard has excessive leaf matter, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
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Administrator/Licensee will remove excess leaf matter and maintain backyard.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 12/12/2022 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/09/2022 at 12:48 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: CENTURION RESIDENTIAL CARE
FACILITY NUMBER: 198600579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, bathroom #1 sink is being held up by a shower curtain rod, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator/Licensee will replace sink.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, insufficient supply of staple nonperishable food for a minimum of one week and fresh perishable foods for a minimum of two days. the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2022
Plan of Correction
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Administrator/Licensee will restock food supply as required and submit photo proof and receipt.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 12/12/2022 03:49 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/09/2022 at 01:06 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: CENTURION RESIDENTIAL CARE
FACILITY NUMBER: 198600579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, construction to bedroom #4 outside wall is being conducted without prior notification to the licensing agency, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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Submit proposal of any construction or alterations before proceeding with construction or alterations.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
Page: 11 of 11