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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602007
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:52:29 PM

Document Has Been Signed on 07/30/2024 12:52 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALKEN CAREFACILITY NUMBER:
198602007
ADMINISTRATOR/
DIRECTOR:		RUALO, MARIA THERESA C.FACILITY TYPE:
735
ADDRESS:13649 FLATBUSH AVENUETELEPHONE:
(562) 929-7382
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Maria Theresa Rualo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 07/30/2024. LPA were met by Staff #1 (S1) and explained the purpose of the visit. Administrator Maria Theresa Rualo arrived shortly after and assisted in tour of facility. The facility has a fire clearance approved for four (4) ambulatory of which two (2) may be non-ambulatory clients. All clients receive services from Harbor Regional Center. LPAs requested and obtained a copy of Personnel Report, and Resident Roster.
The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.


· LPA observed that the facility has an infection control plan in place.

Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1 and observed the following: The facility is a single-story building in a residential area, with a kitchen, dining room, living room, family room, 4 client bedrooms, 2 bathrooms, backyard with shaded area and a garage. · All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.

· Hallway closet: Contained plenty of linens, towels, PPE’s, and hygiene products.

· Fireplace is secured, closed, and inaccessible to clients.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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Document Has Been Signed on 07/30/2024 12:52 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/30/2024 at 11:52 AM
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: ALKEN CARE
FACILITY NUMBER: 198602007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA, Daniel Konishi measured client’s restroom #2 water temperature read at 122.7 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALKEN CARE
FACILITY NUMBER: 198602007
VISIT DATE: 07/30/2024
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· Beds have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition.

· Fire extinguisher was observed in the kitchen and last reviewed 06/21/2024.


· Smoke/carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked in the hallway closet away from food supplies.
· Sharps are kept locked in the hallway closet.
· Shared client bathrooms were observed to be clean and contained soap and paper towels.
Signs promoting hand washing were observed.
· Water temperature in this bathroom#1 was measured at 106.5 degrees F but the Bathroom #2 was measured at 122.7 degrees F which does not meet the required 105 – 120 degrees F per Title 22 Regulations.

Operational Requirements:
· The facility is licensed to serve four (4) ambulatory clients of which two (2) may be non-ambulatory.
· Care and supervision to meet the clients’ needs was observed.

Staffing:
· A total of three (3) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate expired on 07/27/2024 but recertification is currently pending and has been verified by the LPA.


· Administrator does have required AIDS/HIV & TB training.
· Four (4) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Facility has per regulation staff training in file.
Client Rights/Information:
· Physician orders were reviewed in client files.
· Internet access is available for the clients use.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALKEN CARE
FACILITY NUMBER: 198602007
VISIT DATE: 07/30/2024
NARRATIVE
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Client Records/Incident Reports:
· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, TB clearance, Individual Program Plan, personal rights, medication records, and Personal and Incidental (P & I) money were reviewed.


Food Services:
· 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.
· Facility has a current restricted Health Care plan in file required for the clients.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records were reviewed.


· First Aid Kit was reviewed and has required items.
· LPA observed cabinet located in the kitchen cabinet to be locked and inaccessible to residents. LPA reviewed four (4) out of four (4) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:
· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.


Disaster Preparedness, and Emergency Intervention:
· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 07/03/2024.


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALKEN CARE
FACILITY NUMBER: 198602007
VISIT DATE: 07/30/2024
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Emergency Intervention:
· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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