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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600918
Report Date: 01/12/2023
Date Signed: 01/13/2023 10:32:00 AM

Document Has Been Signed on 01/13/2023 10:32 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:ROBILYN GUEST HOME, INC.#3FACILITY NUMBER:
198600918
ADMINISTRATOR:CARLOS CUNANANFACILITY TYPE:
735
ADDRESS:10909 HAYFORD STTELEPHONE:
(562) 868-0464
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carlos CunananTIME COMPLETED:
01:00 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Carlos Cunanan, who assisted with the visit.

LPA Rea discussed infection control practices with Mr. Cunanan, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed (4) resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilets. Showers also have non-skid materials. The hot water temperature measured at 105.6 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors & carbon monoxide detector were tested and operational. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Deficiencies cited on 809-D. Exit interview held and a copy of the report, and appeal rights were provided to Mr. Cunanan.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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 01/13/2023 10:32 AM - It Cannot Be Edited


Created By: Angelica Rea On 01/12/2023 at 12:22 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: ROBILYN GUEST HOME, INC.#3
FACILITY NUMBER: 198600918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)


This requirement is not met as evidenced by: LPA observed that Resident #1 had PRN Ibuprofen prescribed on 12/7/22 RX: 1039032, and did not have Dr's orders in file.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 medication review(s) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2023
Plan of Correction
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Administrator will ensure that Resident(s) have Dr's orders on file for all medication(s) prescribed. Administrator will send proof of correction to LPA and will ensure that Staff receive medication training, and will send proof of training.
Type A
Section Cited
CCR
80075(b)(5)(B)


This requirement is not met as evidenced by: LPA observed that Resident #2 was prescribed PRN Ibuprofen on 12/6/19 RX: 731603 and the medication was not available for review at the time of the visit. LPA observed that Resident #3 was prescribed PRN Guaifenesin w/ Cod on 12/14/20 RX: 750163, and PRN Acetaminiphen on 12/18/20 RX: 750544, and medication was not available for review at the time of visit.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 medication review(s) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2023
Plan of Correction
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Administrator will ensure that resident(s) medications which have been prescribed are available at the facility as required. Administrator will send proof of correction to LPA and will ensure that Staff receive medication training, and will send proof of training.
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:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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