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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600628
Report Date: 03/11/2023
Date Signed: 03/11/2023 03:07:04 PM

Document Has Been Signed on 03/11/2023 03:07 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: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: 4DATE:
03/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Jennifer Tayag - Direct Support StaffTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit using the CARE tool at the facility. LPA met with Jennifer Tayag Direct Support Staff (DSP) and explained the reason for the visit.

The facility is licensed to serve (6) six non-ambulatory clients ages 18-59. Developmentally disabled only. The facility is located in a residential neighborhood and it consist of (4) four client rooms, (2) two client bathrooms, a kitchen, a dining room, a living room, a laundry room, a front yard, a back yard, and an attached garage inaccessible to the clients.
LPA Flores conducted a tour of the facility with Jennifer Tayag DSP and observed the following:
Living room and dining room are clean and have seating space. Kitchen was observed, refrigerator and freezer has sufficient food for at least (2) days worth of perishables and (7) days of non-perishables. A small medication refrigerator was lock. Cleaning solution was observed under the sink cabinet and unlock during the visit. Medication and sharps cabinet located to the left of the kitchen was unlock during the visit. (4) client bedrooms were observed, each with sufficient lighting, bedding supplies, and furniture. Client #1 has a half bed rail in bed and an exemption request was submitted and approved on 12/1/20 by the department. Bedroom #4 (BR4) was observed with blanket and towel by the exit door per DSP water had come in due to the rain, mildew smell was noticed and water damage was observed in the lower corner next to the hinges of the door. (2) bathrooms were observed in working condition and water temperature was measured as follow: temperature in bathroom #1 tested at 107.4 degrees F., and in bathroom #2 tested at 109.7 degrees F. which is within the required 105-120 degrees F. Interlace Smoke/Carbon monoxide detectors were tested and in working condition. The backyard has a covered sitting area and a fenced/covered pool which is out of order. LPA Flores reviewed medication, files and P&I money for (4) clients. LPA reviewed files for (5) staff. Last fire drill was conducted on 12/10/22. Administrator certificate #6022165735 exp. date: 12/22/24 was observed for Margie Canlobo. Emergency disaster plan LIC 610D 10/03 was reviewed.
Deficiencies were noted on LIC 809D under Title 22 Regulations Division 6 Chapter 1.
Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2023
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 3
Document Has Been Signed on 03/11/2023 03:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/11/2023 at 02:16 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: 03/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 cleaning solution was observed under kitchen sink and sharps cabinet were unlock at the time of the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2023
Plan of Correction
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Licensee will certify via LIC 9098 and schedule in-service training by POC due date 3/12/23. Licensee will provide in-sevice training and submit to the department by 3/20/23.
Type A
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medication cabinet was not lock at the time of the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2023
Plan of Correction
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Licensee will certify in LIC 9098 and schedule in-service training by POC due date 3/12/23. In-service training should be provided and submit to the department by 3/20/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/11/2023 03:07 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/11/2023 at 02:16 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: 03/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in BR4 was observed to have water damage and smell of mildew was notice which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Licensee will contact a mold/mild company to evaluate BR4 and provide proper repairs and prevention of water entering BR4. Invoices for services and repairs, and pictures to be submitted to the department by POC due date 3/24/23.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 emergency disaster plan was not updated to current form LIC 610D 12/21 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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Licensee will update emergency disaster plan and submit to the department by POC due date 3/24/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2023


LIC809 (FAS) - (06/04)
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