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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601521
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:40:55 PM

Document Has Been Signed on 12/18/2023 01:40 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:SIESTA CARE HOMEFACILITY NUMBER:
198601521
ADMINISTRATOR:RHEA ORTIZ-LUISFACILITY TYPE:
735
ADDRESS:335 S. SIESTA AVETELEPHONE:
(626) 333-1923
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 4DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Telebrico LeilaniTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit utilizing the Infection Control Tool. LPA met with House Manager Telebrico Leilani who assisted with the visit. LPA explained the reason for the visit. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. Facility submitted infection control plan to CDSS. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and receive services from San Gabriel /Pomona regional Center. However, there are 3 residents over the age of 60, which exceeds 50% of census. The licensee must request an exception in order to accept or retain the individual. All four (4) clients were at the Day program at the time of visit.

This is a single story home located in a residential neighborhood. It consists of the following: 4 client bedrooms, 2 staff rooms, 1 full client bathroom, and 1 1/2 client bathroom, 1 full staff bathroom, living/dining room area, kitchen, detached garage , garage closet room, backyard, and front yard with patio furniture. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Linens and personal hygiene supplies are stored in hallway closet. Laundry area was observed in the garage.

The bathrooms are clean and have the required grab bars and non-skid mat. The water temperature was tested 112.6 degrees which is within the required 105 - 120 degrees. LPA observed that trash bins in clients bathrooms didn't have a covers/lids. Facility has sufficient perishable and non-perishable food. All the appliances in the kitchen are clean and working properly. Sharps and cleaning supplies were stored in a locked room that is attached to the garage and inaccessible to clients. The common areas such as living room, dining room are clean and have the required furniture. LPA observed the centrally stored medication area to be locked and inaccessible to clients.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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 12/18/2023 01:40 PM - It Cannot Be Edited


Created By: Nune Margaryan On 12/18/2023 at 11:50 AM
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: SIESTA CARE HOME
FACILITY NUMBER: 198601521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

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: Trash bins in clients bathrooms observed without covers/ lids which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licensee/Administrator was agree to buy new trash bins for both bathrooms.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


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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: SIESTA CARE HOME
FACILITY NUMBER: 198601521
VISIT DATE: 12/18/2023
NARRATIVE
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The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detectors were working properly, fire extinguishers were fully charged and operational. LPA reviewed clients and staff files. Staff working at facility have fingerprint clearances. Upon reviewing client's files LPA observed that there are a total of 3 clients over the age of 59, and an Exception Waiver for clients is not in place. LPA reviewed clients medications. Medications are documented and stored properly.

Deficiencies are being cited. See LIC 809D.

Exit interview was conducted with House Manager. A copy of the report, appeal rights was issued.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/18/2023 01:40 PM - It Cannot Be Edited


Created By: Nune Margaryan On 12/18/2023 at 12:35 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: SIESTA CARE HOME
FACILITY NUMBER: 198601521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request
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 above in that there are a total of 3 clients over the age of 59, and an Exception Waiver for clients is not in place. The census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety, or personal rights risk to persons in care
POC Due Date: 12/29/2023
Plan of Correction
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Licensee / Administrator shall submit an Exception request for 3 clients by POC due date, and/or clients shall be relocated. If an extension is required submit a written request by the due date.

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023


LIC809 (FAS) - (06/04)
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