<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601369
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:46:24 PM

Document Has Been Signed on 10/29/2024 03:46 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:MORALES FAMILY HOMEFACILITY NUMBER:
198601369
ADMINISTRATOR/
DIRECTOR:		ERNEST LUNAFACILITY TYPE:
735
ADDRESS:1821 PIERCE PLACETELEPHONE:
(626) 573-9126
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 3DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Ernest Luna, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:54 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA was not allowed entry by new staff initially for about 40 minutes until after LPA spoke with Administrator Ernest Luna via phone and Administrator Ernest Luna arrived about 50 minutes later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one-story Adult Residential Facility (ARF) Level 2 facility consisting of 2 client bedrooms, including 2 shared bedrooms and 2 bathrooms, kitchen, dining room, activities room, laundry section, medication cabinet, staff room and outdoor shaded area. This facility is licensed for a capacity of 4 clients and today's census was 3.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan was posted at the facility.


Physical Plant & Environment Safety: The facility is free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 112.2 -116.9 degrees F which is within required range of 105.0 -120.0 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 08/24/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed inspected yearly.

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 5
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: MORALES FAMILY HOME
FACILITY NUMBER: 198601369
VISIT DATE: 10/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from 809)

Operational Requirements: Facility is complying.

Staffing: There appears to be sufficient staffing at the facility. CPR/First aid certificates are on file. Administrator Ernest Luna's certificate expires on 11/30/2024.

Personnel Records-Training: One new Staff does not has criminal record clearance. Staff files are maintained at the facility. Staff have current CPR/first aid training and documentation of ongoing training.


Client Rights-Information: Client personal rights poster is posted at the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. IPP is updated for all clients
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the den. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 3 clients' medications, all medication is administered according to doctor’s orders.
Incidental Medical Services: Facility is complying and has documentation on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan at facility but needs updating.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Deficiencies cited during today's visit.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/29/2024 03:46 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/29/2024 at 02:59 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: MORALES FAMILY HOME
FACILITY NUMBER: 198601369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80044(a)(2)
Inspection Authority of the Licensing Agency (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Section 1533, (2) Health and Safety Code Section 1533 provides in part: ...any duty authorized officer, employee, or agent of the State Department of Social

Social Services may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and interview the licensee did not comply with the section cited above. LPA arrived at facility, knocked on door, introduced self and new caregiver Anita stated she was instructed to not allow entry to anyone. LPA got a hold of Administrator about 40 minutes later and Administrator came to the home and allowed LPA entry. Administrator confirmed that he told his caregiver to not allow entry to anyone. LPA announced visit and knocked on the iron door numerous times to gain access to this facility and was unsuccessful. which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalties issued.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
Administrator to review 80044(a)(2) and self-certify understanding of this requirement and submit a written statement to LPA Lopez by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/29/2024 03:46 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/29/2024 at 03:10 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: MORALES FAMILY HOME
FACILITY NUMBER: 198601369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review], the licensee did not comply with the section cited above. One staff was not fingerprinted and associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
Administrator will obtain fingerprint clearance and associate staff before she can report to work..
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5