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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600583
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:20:37 PM

Document Has Been Signed on 08/14/2023 03:20 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: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: 4DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Rana Chapkahneh- AdmistratorTIME COMPLETED:
02:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Jorge Lizarraga/Direct Support Professional (DSP) and explained the purpose of today's visit. At 11:30am, Rana Chapkahneh/Admistrator arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station at the entrance, but LPA did not observe PPE supplies. The facility has submitted an Infection Control Plan. The facility has also submitted a COVID-19 Mitigation Plan. Facility does not have COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single storey home located in a residential neighborhood. Facility has (3) client bedrooms and (2) full bathrooms, kitchen, living room, dining area, backyard, and detached garage. It is licensed for Developmentally Disabled adults 18 to 59 years old, and (2) non ambulatory only, with restricted health conditions. Currently, there are four (4) clients living in the facility. All clients residing at this facility receive case management services provided by Harbor Regional Center. Facility is Level 4I. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. LPA observed that a bed with full rails in bedroom #3. Administrator stated that the facility accepted a new client on Fri., 8/11/2023 to provide temporary respite care for Client #4 (C4). Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Additional PPE supplies are also stored in the detached garage. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet by the laundry area and inaccessible to clients. There is (1) fire extinguisher observed mounted on the kitchen wall and was last serviced on 7/16/2021. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 114.deg F in bathroom #1 and 110.6 deg F in bathroom #2.

Operational Requirements: A Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Administrator will send a copy of the Infection Control Plan to LPA. Administrator cannot locate and provide a copy of the Liability Insurance and Surety bond to LPA. Administrator agreed to send it to LPA and ensure that both insurance are valid. Care and supervision to meet the residents needs was observed.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DE LEON HOME - BELLFLOWER
FACILITY NUMBER: 198600583
VISIT DATE: 08/14/2023
NARRATIVE
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Staffing: A total of eight (8)staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance and have the required training and associated to the facility.

Personnel Records-Training: Administrator certificate expires 5/04/2024. Staff have criminal background clearance and training. Two (2) staff files were reviewed. Personnel records have health/TB screenings and First Aid/CPR training.

Client Rights-Information: Client personal rights are posted.

Client Records-Incident Reports: A total of two (2) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C2 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. Medical and dental transportation is provided.

Incident Medical and Dental: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. Records of resident Appraisal and Needs services plans are part of Emergency training. Fire Drill was last conducted on 1/19/2023.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted, and a copy of this report was provided to Rana Chapkahneh, Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/14/2023 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/14/2023 at 01:42 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during physical plant inspection, the fire extinguisher mounted on the kitchen wall had an expired service tag dated 7/16/2021 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 08/15/2023
Plan of Correction
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Administrator shall submit proof of purchase of the fire extinguisher and provide purchase receipt to LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/14/2023 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/14/2023 at 01:42 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that the facility does not have current and valid Surety Bond insurance in place which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/28/2023
Plan of Correction
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Administrator shall have a valid Surety Bond on file. Submit proof of valid insurance to CCL/LPA by POC due date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 which during the inspection LPA observed that the last fire drill was conducted on Jan 19, 2023, which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/28/2023
Plan of Correction
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Administrator is to ensure that Fire drill will be conducted at least once every three months and will include all facility staff who provide or supervise client care and supervision. Administrator will submit proof of training including names and signature of staff and date the training was conducted to CCL/LPA by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2023 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/14/2023 at 01:49 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(E)(1)
80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(8) Not to be placed in any restraining device. Postural supports may be used under the following conditions:
(E) Under no circumstances shall postural supports include tying of, or depriving or limiting the use of, a client's hands or feet.
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed with prior licensing approval. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee failed to ensure bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice. LPA observed that the bed for Client #4 has full rails , which poses a potential health, safety or personal rights risk to clients in care.

POC Due Date: 08/15/2023
Plan of Correction
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Administrator will remove the full rails from Client #4 bed, and obtain a physician order for rails if needed. Submit proof of order and photos that rails had been removed to CCL/LPA by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/14/2023 03:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/14/2023 at 01:54 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
80077.3(a)(3)(C)
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that the facility has not conducted a fire drill since 1/19/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/28/2023
Plan of Correction
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Administrator will ensure that fire and earthquake drills are conducted at least once every three months, and maintain a record of the said drills. Submit a copy of the drill with the staff name, signature and date training was ocnducted to CCL/LPA by POC due date.
Type B
Section Cited
HSC
1569.605

1569.605 Liability insurance; coverage requirements
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in that the Administrator could not provide a copy of a valid Liability insurance, which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/28/2023
Plan of Correction
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 Administrator shall renew the liability insurance and send to CCL/LPA by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


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