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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600628
Report Date: 01/31/2022
Date Signed: 01/31/2022 04:04:07 PM

Document Has Been Signed on 01/31/2022 04:04 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:CIENEGA RESIDENTIAL CAREFACILITY NUMBER:
198600628
ADMINISTRATOR:MARGIE CANLOBOFACILITY TYPE:
735
ADDRESS:20829 EAST CIENEGA AVENUETELEPHONE:
(626) 257-3616
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Margie Canlobo, Administrator
Jennefer Tayag, Staff		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve six (6) Developmentally Disabled, non-ambulatory clients, from age 18-59. Client census is six (6). The facility is vendorized through San Gabriel/Pomona Regional Center. The annual fee is paid. LPA met with Administrator and Staff, who assisted with visit. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility inside and outside. Facility is a single-story home located in a residential neighborhood consisting of four (4) client bedrooms, two (2) bathrooms, living room, family room, dining room, kitchen, laundry room, office space, and secured pool with a locked gate at the backyard.

Bathrooms are operational. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Carbon monoxide detectors and smoke detectors are operable. Hot water temperature measured at 113.5 degrees Fahrenheit. (-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628
VISIT DATE: 01/31/2022
NARRATIVE
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Medications are centrally stored and locked. Medications were properly logged and current. Hazardous items are locked and inaccessible to clients. The secured pool at the backyard which is not in use with a locked gate is inaccessible to the clients. Fire extinguisher was fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. Last disaster drill was conducted on 7/11/2021.

Deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2022 04:04 PM - It Cannot Be Edited


Created By: Bonnie Tao On 01/31/2022 at 03:48 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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds.

The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Four stove top burners of the cooking stove are not working.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 02/10/2022
Plan of Correction
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Licensee/ Administrator will ensure cooking stove is operable by repairing it or replacing it with a new one. The POC must be corrected by POC.
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:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
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