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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601715
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:12:45 PM

Document Has Been Signed on 10/29/2024 12:12 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/
DIRECTOR:		LILIBETH ESGUERRA-NUCKOLLSFACILITY TYPE:
735
ADDRESS:2054 LORAINE STTELEPHONE:
(626) 964-4980
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Lilibeth EsguerraTIME VISIT/
INSPECTION COMPLETED:
12:15 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. The purpose of the visit was explained to staff Jorielle Asprec. Administrator Lilibeth Esguerra arrived shortly after. The facility is licensed for 4 developmentally disabled residents ages 59 and under. The facility is licensed as a level 4A RCFE vendored by San Gabriel/Pomona Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A fire clearance for 4 non-ambulatory residents ages 59 and under was approved on 11/30/22. Facility handles resident P & I monies and has a current Surety Bond that expires 4/26/2025.

Physical Plant/Environment Safety: 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. The facility has one (1) fully charged fire extinguisher and a fire pull alarm in the living room. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances were observed locked and inaccessible to residents.

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

Personnel Records/Staff Training: Administrator certificate expires 6/25/2025. Four (4) staff files were reviewed. Staff have criminal background clearance, health and TB clearance, and 1st Aid/CPR training. Proof of in-service training that includes HCBS Final rule was observed in staff files.

****Report narrative continues next page.*****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
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: 3 of 5
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: 10/29/2024
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
Resident Records/Incident Reports: Four (4) resident files were reviewed. They contained admission agreements, IPPs, Behavior Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. Two (2) out of the four (4) residents are over the age of 59, presently not exceeding 50 percent of the census.

Home and Community-Based Services (HCBS) Federal Requirements were posted.



Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Daily activities and weekly calendar of activities was reviewed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No residents have a modified diet plan.

Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by facility staff.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 6/30/2024.

Residents with Special Health Needs: No residents are receiving hospice services or home health services. There are no residents have a restricted health care plan.

No deficiencies were observed.



Exit interview was conducted with Administrator A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
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: 5 of 5