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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602037
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:46:59 AM

Document Has Been Signed on 05/09/2022 11:46 AM - 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:MORENO FAMILY HOMEFACILITY NUMBER:
198602037
ADMINISTRATOR:BENNY MORENOFACILITY TYPE:
735
ADDRESS:14837 GALE AVE.TELEPHONE:
(626) 968-8420
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Benny Moreno (Administrator)TIME COMPLETED:
12:00 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) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Benny Moreno (Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 18 through 59. 6 ambulatory only.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, 3 client bedrooms, 1 staff bedroom, 2 bathrooms, attached garage/laundry area.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. There are no pools or large bodies of water on the premises. There are no firearms on the premises. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature measured at 112.4 degrees F in the east bathroom. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Initial Needs and Services Plan is updated. Staff responsible for direct care and supervision have current first aid. LPA was allowed to enter the facility to conduct the inspection. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible.
Knife drawer is unlocked in the kitchen. Open pack of butter and an open can of beans were observed in the refrigerator. Obstructions in both the east and west passage ways was observed. LPA observed that all kitchen flooring tiles has been removed due to renovations.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Benny Moreno.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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 4
Document Has Been Signed on 05/09/2022 11:46 AM - It Cannot Be Edited


Created By: Kruz Long On 05/09/2022 at 10:40 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: MORENO FAMILY HOME
FACILITY NUMBER: 198602037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)


This requirement is not met as evidenced by: LPA observed an unlocked drawer in the ktichen containing knives.
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
1
2
3
4
Licensee shall locked knives in a location inaccessible to clients.

Note: Knives are lock in the garage during time of visit.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/09/2022 11:46 AM - It Cannot Be Edited


Created By: Kruz Long On 05/09/2022 at 10:47 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: MORENO FAMILY HOME
FACILITY NUMBER: 198602037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(14)


This requirement is not met as evidenced by: Open pack of butter and an open can of beans were observed in the refrigerator.
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
1
2
3
4
Licensee shall immediately discard the uncovered food items from the refrigerator.

Note: Uncovered food times was discarded at time of visit.
Type B
Section Cited
CCR
80087(c)


This requirement is not met as evidenced by: Obstructions in both the east and west passage ways was observed.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
1
2
3
4
Licensee shall immediately remove all obstructions from the east and west passage ways.

Note: Licensee removed all obstructions from both the east and west passage ways.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/09/2022 11:46 AM - It Cannot Be Edited


Created By: Kruz Long On 05/09/2022 at 11:01 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: MORENO FAMILY HOME
FACILITY NUMBER: 198602037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by: LPA observed that all kitchen flooring tiles has been removed due to renovations.
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above,] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2022
Plan of Correction
1
2
3
4
Licensee shall ensure that all client do not have access to the kitchen area until renovations are complete. Once renovations are complete, Licensee shall provide proof to the department by the POC date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


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