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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600583
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:06:40 PM

Document Has Been Signed on 09/01/2022 04:06 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:DE LEON HOME - BELLFLOWERFACILITY NUMBER:
198600583
ADMINISTRATOR:MAUREEN DELEONFACILITY TYPE:
735
ADDRESS:10240 VAN RUITENTELEPHONE:
(562) 920-3241
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Rana Chapkahneh- AdmistratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced required annual inspection at the facility. LPA Maldonado met with administrator Rana Chapkahneh and explained the purpose of the visit. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the facility physical plant with the administrator, observed the food supply, reviewed COVID-19 procedures, and client's medications. The facility has submitted a mitigation plan- approved on 08/17/21.

The facility is licensed to have four (4) Developmental disabled clients between the ages of 18-59 years of age, two (2) non-ambulatory with restricted health conditions. The home consists of three (3) client bedrooms, two (2) bathrooms, living room, kitchen, dining area, laundry area, and detached garage. LPA observed all 3 client bedrooms to have the required linens, furniture and sufficient lighting. The facility was at a comfortable 77*F, as observed on the thermostat in the hallway. All entry ways and walkways are free of debris and hazards. The bathrooms were observed to have a working shower, toilet, and wash basin, and were all fully stocked with hand soap and paper towels. The water temperature in bathroom# 1 measured at 128.7*F and measured at 134.7*F in bathroom# 2, which is currently not in compliance with California Code of Regulations- Title 22. Sufficient PPE was observed at the entrance of the facility- readily available to the clients in care, and additional PPE was stored in the garage. The food supply in the facility was observed to have the required two-day non-perishables, seven-day of non-perishables, and emergency food supplies. The laundry room was observed to have working appliances and in good repair. All toxins, cleaning supplies, sharps, and medications, were locked in a cabinet above the laundry appliances, separate from each other. The smoke/carbon monoxide detectors are interconnected, were tested and were observed to be in working conditions. LPA reviewed 3 of 4 client's medications and were observed to have current and accurate Medication Administration Records.

(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DE LEON HOME - BELLFLOWER
FACILITY NUMBER: 198600583
VISIT DATE: 09/01/2022
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During today's visit, deficiencies were observed per Title 22, Division 6, Chapter 1 and will be cited on the LIC809-D.

An exit interview was conducted with administrator Rana Chapkahneh and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/01/2022 04:06 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 09/01/2022 at 03:45 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: DE LEON HOME - BELLFLOWER
FACILITY NUMBER: 198600583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care... shall deliver hot water. (1) Hot water temperature controls shall be maintained... 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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathoom sinks, where the water temperature measured at 128.7*F and 134.7*F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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The adminstrator turned down the temperature of the water on the water heater during the visit. LPA checked the water temperature at the end of the visit and it measured at 117.4*F in bathroom# 1 and 115.7*F in bathroom# 2. The administrator brought the water temperature to compliance and nothing further is needed. POC will be cleared.
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:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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