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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601715
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:52:06 PM

Document Has Been Signed on 10/03/2023 03:52 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: 4CENSUS: 4DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Lilibeth Esguerra-NuckollsTIME COMPLETED:
03:55 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) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Administrator Lilibeth Esguerra-Nuckolls. There are four (4) ambulatory developmentally disabled adults. Two (2) residents are over the age of 59, and two (2) are under age 59. The facility is licensed as a level 4A home vendored by San Gabriel/Pomona Regional Center. Twelve (12) Adult CARE tool domains were observed and reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan and COVID-19 Mitigation Plan, and Monkey Pox Plan were reviewed.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. It consists of 4 resident bedrooms, 1 office room, 2 bathrooms, kitchen, dining room, living room, outdoor patio, and a detached garage with laundry area.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fully charged fire extinguisher.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.


****Report narrative continues next page.*****
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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 4
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: MORIAH'S BOARD AND CARE
FACILITY NUMBER: 198601715
VISIT DATE: 10/03/2023
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
Operational Requirements:
  • Fire clearance is approved for four (4) non-ambulatory residents only.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by clients.
  • Facility has a current Surety Bond.

Staffing:
  • A total of 6 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 6/25/2023. Per Licensee, the Certification unit received the recertification training proof, but as of today the certificate has not been processed.
  • provided.
  • Five (5) staff files were reviewed. Personnel record, Criminal Record Clearance, health screening/TB clearance, training, zero-tolerance policy, and 1st Aid/CPR was on file.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, Personal & Incidental (P & I) monies/records, and Medication Administration Records medication administration records.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • There are no physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: MORIAH'S BOARD AND CARE
FACILITY NUMBER: 198601715
VISIT DATE: 10/03/2023
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
Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. They are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All residents have a Needs and Services Plan, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention:
  • The updated LIC 610D Emergency Disaster Plan that contains emergency evacuation information has not been developed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. Citation was issued.
  • First Aid Kit and Manual were observed.
  • The last emergency drill was conducted 7/28/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, a deficiency was cited.


Exit interview conducted with Administrator Lilibeth Esguerra-Nuckolls A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2023 03:52 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/03/2023 at 03:32 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: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that Licensee does not have in place the updated LIC 610D Emergency and Disaster Plan form, which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit a copy of the updated LIC 610D Emergency and Disaster Plan. Facility shall maintain the form on file at the facility.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


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