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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600579
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:54:25 PM

Document Has Been Signed on 10/05/2023 01:54 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:CENTURION RESIDENTIAL CAREFACILITY NUMBER:
198600579
ADMINISTRATOR:PORTER, FRANCES PORTERFACILITY TYPE:
735
ADDRESS:303 ARDILLA AVE.TELEPHONE:
6263699185
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Perla ChapaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit utilizing the Infection Control Tool. LPA met with staff Perla Chapa who assisted with the visit. Administrator Angela Porter arrived shortly after. LPA explained the reason for the visit. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. Facility submitted infection control plan to CDSS. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and receive services from San Gabriel /Pomona regional Center. All four (4) clients were at the Day program at the time of visit. The facility is located in a residential area. LPA toured the home and inspected living room, dining room, kitchen, 4 bedrooms, 2 bathrooms and the garage/office. Laundry area was observed in the garage / office. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating / patio area for the clients located in the backyard. Passageways and exits are free of obstruction. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the garage / office. All required posters were posted at the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Client bedrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms were toured. LPA observed that bathroom #1 doesn't have a trash bin and bathroom #2 trash bin observed without cover. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients.

The fire extinguisher observed to be fully charged. Smoke detector observed to be fully operational. The facility has a fire pull alarm system. LPA observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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Document Has Been Signed on 10/05/2023 01:54 PM - It Cannot Be Edited


Created By: Nune Margaryan On 10/05/2023 at 12:19 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: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1)
is not associated to the facility; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2023
Plan of Correction
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Licensee / Administrator will associate Staff #1 via Guardian and will submit prove 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


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Document Has Been Signed on 10/05/2023 01:54 PM - It Cannot Be Edited


Created By: Nune Margaryan On 10/05/2023 at 12:26 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: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. At the time of visit LPA observed that Bathroom #1 doesn't have a trash bin and Bathroom #2 trash bin doesn't have a cover which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Licensee / Administrator buy 2 trash bins at the time of visit. The citation was cleared today. No further action needed
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


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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: CENTURION RESIDENTIAL CARE
FACILITY NUMBER: 198600579
VISIT DATE: 10/05/2023
NARRATIVE
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LPA reviewed client's files and observed that there are a total of 3 clients over the age of 59, and an Exception Waiver for clients is not in place. LPA reviewed staff records and observed that Staff #1 has fingerprint clearances, but not associated to the facility. . LPA reviewed clients medications. Medications are documented properly and given as prescribed.

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: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/05/2023 01:54 PM - It Cannot Be Edited


Created By: Nune Margaryan On 10/05/2023 at 01:02 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: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section above in that there are a total of 3 clients over the age of 59, and an Exception Waiver for clients is not in place. The census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 10/16/2023
Plan of Correction
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Licensee / Administrator shall submit an Exception request for 3 clients by POC due date, and/or clients shall be relocated. If an extension is required submit a written request by the due date.

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 Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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