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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601521
Report Date: 11/23/2024
Date Signed: 11/23/2024 02:18:49 PM

Document Has Been Signed on 11/23/2024 02:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIESTA CARE HOMEFACILITY NUMBER:
198601521
ADMINISTRATOR/
DIRECTOR:
RHEA ORTIZ-LUISFACILITY TYPE:
735
ADDRESS:335 S. SIESTA AVETELEPHONE:
(626) 333-1923
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
11/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:DSP Marissa CasugaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Marissa Casuga at approximately 11:55 AM and explained reason for visit. House Manager Telebrico Leilani was notified by telephone.

The facility is licensed to serve as an Adult Residential Facility for 6 (6) non- ambulatory clients in the age range of 18 through 59. All clients are serviced by San Gabriel Pomona Regional Center. This is a single-story home located in a residential neighborhood. It consists of the following: 4 client bedrooms, 2 staff rooms, 2 client bathrooms, 1 full staff bathroom, living/dining room area, kitchen, detached garage, outside closet room, backyard, and front yard with patio furniture.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in living room. Cleaning supplies and toxic substances are inaccessible to clients locked outside closet room. LPA observed sharps in kitchen drawer with no lock deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2024
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 11/23/2024 02:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 11/23/2024 at 01:47 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: 11/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
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.

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 sharps were accessible to clients in an unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2024
Plan of Correction
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DSP worker removed sharps and locked them under sink. Administrator will conduct a training with staff and send it to LPA by POC due 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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/23/2024 02:18 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 11/23/2024 at 01:47 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: 11/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Administrator certificate expired in 2022 and facility could not provide current or pending certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
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House Manager will send current certificate by email to LPA.
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) clients did not have a physicians report and tb clearance, two (2) out of two (2) clients did not have a current IPP report and one(1) client did not have a medical consent form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2024
Plan of Correction
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House Manager will send current physicians reports with TB for clients C1-C3, current IPP report for clients C2-C3, and C2 medical consent form to LPA by POC 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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2024


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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SIESTA CARE HOME
FACILITY NUMBER: 198601521
VISIT DATE: 11/23/2024
NARRATIVE
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator certificate was expired. Three (3) client files were reviewed and were missing physicians report, TB clearance, and current individual program plan (IPP)report. Last fire/earthquake drill was conducted in November of 2024. Infectious control plan was reviewed. One (1) staff and one (1) client were interviewed. Three (3) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to DSP worker Marissa Casuga.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2024
LIC809 (FAS) - (06/04)
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