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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601959
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:09:47 PM


Document Has Been Signed on 07/28/2022 01:09 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:MOM & DAD'S HOUSEFACILITY NUMBER:
198601959
ADMINISTRATOR:IVONNE A. MEADERFACILITY TYPE:
740
ADDRESS:4340 CONQUISTA AVE.TELEPHONE:
(562) 627-0390
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY:6CENSUS: 6DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Yamilex Razo - AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Caregiver Jose Rodriguez and explained the reason for the visit. The administrator Yamilex Razo arrived shortly after. The facility is licensed to serve six non-ambulatory residents ages 60 years and above and approved for four hospice waivers. Facility currently has 5 non-ambulatory and 1 ambulatory resident. The facility is located in a residential area. A tour of the single-story facility included: living room, family room, kitchen, dining area, 5 resident bedrooms, 2 bathrooms, front yard, backyard and attached garage.

LPA and Jose Rodriguez toured the facility and the following was observed: Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 113.9 degrees F and 116.5 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen in each resident bedroom’s closet and clean towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There are two carbon monoxides in the hallways and are properly operating. There is a fire extinguisher in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked in a kitchen cabinet and are inaccessible to residents. First Aid kit was fully stocked with current manual and it is kept in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction.
(CONTINUED TO LIC 809C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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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: MOM & DAD'S HOUSE
FACILITY NUMBER: 198601959
VISIT DATE: 07/28/2022
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The facility has a video camera monitor system in all common areas and hallway. All residents signed the video camera monitor system plan of operation and there are signs stating "security cameras in use".

Residents medication are centrally stored in a locked cabinet in the dining area. Residents and staff files are centrally stored in the garage. LPA reviewed medication for all 6 of the residents and observed that medications are documented properly and given as prescribed for 4 out of 6 residents. R1's Quetiapine Fumarate 50MG capsule for date 07/01/2022 was still in the bubble pack and R2's Acidophilus 175mg capsule for date 07/25/2022 was still in the bubble pack. There was no notes available to explain reason why those capsules were not given to R1 and R2. LPA reviewed files for all 6 residents and 2 staff. No issues were found with the files. LPA observed administrator certificate for Yamilex Razo – 6055374740 with an expiration date of 03/08/2024.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the garage.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit. Please refer to LIC 809D. Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/28/2022 01:09 PM - It Cannot Be Edited

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: MOM & DAD'S HOUSE
FACILITY NUMBER: 198601959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:

(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, LPA observed R1's Quetiapine Fumarate 50MG capsule for date 07/01/2022 was still in the bubble pack and R2's Acidophilus 175mg capsule for date 07/25/2022 was still in the bubble pack. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Administrator/Licensee to notify R1 and R2's Physicians regarding the missed medications. Administrator/Licensee to conduct in service medication training with staff members who pass out medications and submit list of attending staff members to CCL 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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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