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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600611
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:45:52 AM

Document Has Been Signed on 01/25/2023 11:45 AM - 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:ABRAJANO GROUP HOMEFACILITY NUMBER:
198600611
ADMINISTRATOR:ABRAJANO, JOSEPHFACILITY TYPE:
735
ADDRESS:5953 E. GALLANT ST.TELEPHONE:
(562) 928-1927
CITY:BELL GARDENSSTATE: CAZIP CODE:
90201
CAPACITY: 12CENSUS: 5DATE:
01/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Caregiver Connie VillanuevaTIME COMPLETED:
12:00 PM
NARRATIVE
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During the course of the Annual Inspection the following deficiency was found:
80075 (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

Medication for all 5 clients showed 01/25 dosage still in the bubble pack and not administered. Caregiver confirmed 1 day of morning medication was missed and not administered.

Deficiency cited on 809 D.

Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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 01/25/2023 11:45 AM - It Cannot Be Edited


Created By: Glenn Trueman On 01/25/2023 at 11:20 AM
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: ABRAJANO GROUP HOME
FACILITY NUMBER: 198600611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
CCR
80075(b)

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Health Related Services
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:

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Licensee to ensure that staff receive medication training from the pharmacy and submit by POC due date the date of training and once training completed submit a signed log of staff who attended.
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Based on interviews and observation, the licensee did not comply with the section cited above with Medication for all 5 clients showing 01/25 dosage still in the bubble pack and not administered. Caregiver confirmed 1 day of morning medication was missed and not administered. which poses an immediate health, safety or personal rights risk to persons in care.
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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:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
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