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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600628
Report Date: 02/22/2024
Date Signed: 02/22/2024 05:54:15 PM

Document Has Been Signed on 02/22/2024 05:54 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:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Jenefer Tayag, DSPTIME COMPLETED:
06:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Lopez met with DSP Jennifer Tayag who allowed entry. LPA explained the purpose of the visit.

The facility is licensed to serve 6 non-ambulatory developmentally disabled clients aged 18 to 59. Currently, there are fsix (4) clients in placement. Two client are over 60 years of age. All clients residing at this facility receive case management services provided by San Gabriel/Pomona Regional Center.

During the visit LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Bathrooms have hand washing signs, soap and paper towels. Per Facility staff all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements.

Refer to LIC 809C for continuation of report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/22/2024 05:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/22/2024 at 05:10 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: 02/22/2024

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. Sink in kitchen does not drain as designed. C3 has bed is in disrepair and unclean under the mattresses. There is a hole in the wall in the laundry room and under the kitchen sink that needs repair and shower has signs of mold in the corners which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Administrator will self certify that the above deficiencies have been repaired and send photos as proof to LPA by POC date.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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, LPA and staff witness ants in the kitchen cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator will self certify that the ants have been addressed ad send copy of pest control invoice.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


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Document Has Been Signed on 02/22/2024 05:54 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/22/2024 at 05:10 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above. C3 is using postural supports, seat belt in wheel chair, and half rails which require a doctor order with instruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator will obtain doctor's orders with instructions for 1/2 bed rail, seat belt in wheel chair and postural supports and send to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


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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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628
VISIT DATE: 02/22/2024
NARRATIVE
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Operational Requirements: Fire Drills are conducted every three months; the last fire drill was conducted on 02/02/2024. Emergency Disaster/ Earthquake Drills are conducted every quarter and the last one was conducted on 02/22/2023. Facility staff conducts drills monthly.

Physical Plant & Environment Safety: The home is located in a residential area, the one-story facility includes a living room, dining room, kitchen, laundry room, 4 client bedrooms including one share bedroom, 2 restrooms, an unattached garage and indoor/outdoor activity areas. LPA observed appropriate furniture, lighting fixtures, personal storage space as required, all beds have adequate amount of linen and mattresses, and box springs are in good repair. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. LPA observed that sufficient toiletries accessible to clients. Water temperature measured between 113.3 – 117.3 degrees F which is within range of 105.0 – 120 Degrees F. Facility temperature was within required range. LPA observed the facility to be unclean in some areas, specifically under C3 mattress and ants were observed in kitchen cabinet. Bedrooms were appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher(s) are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. Exits were marked with signs. Notifications and postings were observed which included personal rights, visitor policy, complaint procedures, menu, and emergency disaster plan. LPA observed signs of mold in one bathroom shower and C3 bed was in disrepair.


Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S2. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator Certificate expired on 12/22/2025
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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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: CIENEGA RESIDENTIAL CARE
FACILITY NUMBER: 198600628
VISIT DATE: 02/22/2024
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Client Rights-Information: Client personal rights and House Rules are posted. Per Facility staff, facility provides wi-fi services for facility clients.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights and current IPPs.C3 is missing current doctor’s order for half bed rails and postural support.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/However LPA and Jenefer noticed ants/insects in the kitchen cabinet. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Staff, there are one client at this home with restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating.

Emergency Intervention: Not Applicable.

Deficiencies noted. Technical advisory also provided. Exit interview and a copy of this report, 809D and appeal rights was provided to Staff Jenifer Tayay.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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