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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601715
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:07:13 PM

Document Has Been Signed on 07/27/2022 04:07 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:MORIAH'S BOARD AND CAREFACILITY NUMBER:
198601715
ADMINISTRATOR:LILIBETH ESGUERRA-NUCKOLLSFACILITY TYPE:
735
ADDRESS:2054 LORAINE STTELEPHONE:
(626) 964-4980
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Lilibeth Esguerra-NuckollsTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Maria Luisa DelRosario and explained the purpose of the visit. Administrator Lilibeth Esguerra-Nuckolls arrived shortly after. The facility is a single story home located in a residential neighborhood. It is licensed for 6 level 4A non-ambulatory clients. It consists of 3 client bedrooms, 1 staff bedroom, 2 bathrooms, dining room, kitchen, living room, backyard, and detached garage. Administrator certificate expires June 25, 2023.

Observations:
  • COVID-19 Infection Control signs were observed in the entrance/bathrooms, and was screened.
  • Bedroom #2 is designated as the COVID-19 isolation room if needed.
  • Three (3) centrally stored resident medication record was reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked cabinet.
  • Client in care does not wear a mask because it is not tolerated due to cognitive impairment.
  • Chemicals/cleaning supplies are stored inaccessible to residents.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Smoke detectors were tested and are operational. Fire extinguisher is fully charged.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • Outdoor and indoor passageways and exit doors are free of debris and obstruction.
  • Kitchen knives/sharps were observed unlocked underneath the kitchen sink.
  • The last emergency disaster drill was conducted on 12/15/2021. Emergency disaster drills must be conducted every 6 months.
NOTE: Infection Control Plan was due June 30, 2022. It has not been submitted to CCL.
Deficiencies are cited. See LIC 809D.
Exit interview was conducted with Administrator Lilibeth Esguerra-Nuckolls. A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 3
Document Has Been Signed on 07/27/2022 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/27/2022 at 03:47 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: MORIAH'S BOARD AND CARE
FACILITY NUMBER: 198601715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

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 in that LPA observed the knives/sharps unlocked underneath the kitchen sink cabinet; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Administrator shall conduct staff training and submit proof of training/staff signatures by tomorrow. Staff locked the sharps drawer immediately during the visit.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/27/2022 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/27/2022 at 03:47 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: MORIAH'S BOARD AND CARE
FACILITY NUMBER: 198601715

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

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 in that the last emergency disaster drill was conducted on December 15, 2021; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2022
Plan of Correction
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Administrator shall complete an emergency disaster drill and provide staff training. Submit a copy of the drill log with staff signatures.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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