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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600583
Report Date: 08/05/2024
Date Signed: 08/05/2024 04:13:53 PM

Document Has Been Signed on 08/05/2024 04:13 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/
DIRECTOR:		MAUREEN DELEONFACILITY TYPE:
735
ADDRESS:10240 VAN RUITENTELEPHONE:
(562) 920-3241
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
08/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Nathaniel Timmons - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Nathaniel Timmons (Caregiver) and explained the reason for the visit, later during visit Assistant Administrator Rana Chapkhaneh arrived to assist with the visit. The facility is licensed to serve (4) Adults ages 18 through 59, (2) of which may be non-ambulatory. Facility currently has 4 Ambulatory clients serviced by Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, staff office, 3 client bedrooms, 2 bathrooms, laundry area, detached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 7/23/24.
(continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/05/2024 04:13 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/05/2024 at 03:28 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with Rana Chapkhaneh and attempted, record review, the licensee did not comply with the section cited above as both the administrator Peggie De Leon and Rana Chapkhaneh have expired Administrator certificates an Rana could not furnish proof of valid certificates and confirmed thier certificate that expired 5/2024 has not been renewed (LPA went on CCL website to verify if Peggie De Leon has a pending or valid certificate and it was not found), this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Administrator/Licensee to show proof of renewal/pending renewal to LPA by POC due date for either Peggie De Leon or Rana Chapkhaneh or both. This may be submitted via email to LPA tena.herrera@dss.ca.gov.
Type B
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and attempted file review, the licensee did not comply with the section cited above as Staff #1 arrived to facility to assist with visit (accessing files) but was not associated to faciltiy, nor, was file available to confirm finger print cleared, staff was called to assist but works and is assiociated to sister facility, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Administrator/Licensee to associate Staff #1 to facility since this is a staff that was used to assist during visit. Proof of association and criminal background clearance to be submitted to LPA via email by POC due date (tena.herrera@dss.ca.gov).
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/05/2024 04:13 PM - It Cannot Be Edited


Created By: Tena Herrera On 08/05/2024 at 03:28 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: 08/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

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 4 of the 6 staff files LPA asked to review were not available during visit and were said to be at sister facility, therefore, LPA was only able to review 2 Staff Files, 1 of which was missing some documents that are also at sister facility, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Administrator/Licensee to review above regulation and fill out the LIC9098 which confirms that this regualtion was reviewed and moving forward files will be made readily available during a visit with Licensing, the LIC9098 is to be emailed to LPA by POC due date tena.herrera@dss.ca.gov.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024


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: 08/05/2024
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA attempted to review (4) staff files during today’s visit, however, files were not readily available and it was told to LPA that staff files were kept at sister facility (citation issued and will be explained on LIC809-D). Administrator Peggie De Leon certificate expired 12/2023 and Assistant Administrator Rana Chapkhananeh (citation will be detailed in the 809-D).
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers.
Incidental Medical & Dental: LPA reviewed 3 client medications with no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report was given to Assistant Administrator Rana Chapkhananeh.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
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