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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602272
Report Date: 12/05/2024
Date Signed: 12/05/2024 04:19:39 PM

Document Has Been Signed on 12/05/2024 04:19 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:HOUSE OF HOPEFACILITY NUMBER:
198602272
ADMINISTRATOR/
DIRECTOR:		REYNAGA, VIVIANAFACILITY TYPE:
740
ADDRESS:14558 BROADWAY STREETTELEPHONE:
(562) 325-0572
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 5CENSUS: 4DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Viviana Reynaga, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted a required unannounced annual inspection using the Inspection Tool. LPA met with the Administrator, Viviana Reynaga and the purpose of the visit was discussed and assisted in the tour of the facility.

The following (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, 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 and observed the following:

The facility is part of a single-story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (3) resident rooms, (2) bathroom for residents, toilet and washbasin. A back yard with shaded area and seating for resident use. There’s a laundry area; with washer and dryer. 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 linen closet: Contained plenty of linens, towels, and hygiene products. Beds have the required furniture including bedframes, dressers, lamps, night stands, and sofas. Beds have the required linen and the linen is in good condition. Fire extinguisher was observed in the dining room last reviewed 02/07/2024.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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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: HOUSE OF HOPE
FACILITY NUMBER: 198602272
VISIT DATE: 12/05/2024
NARRATIVE
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Physical Plant/Environment Safety [Cont.]:

Carbon monoxide detectors are tested and in working condition. Cleaning supplies are kept locked in the hallway away from food supplies. Sharps are kept locked in a kitchen drawer. Shared resident bathrooms were observed to be clean and contained soap and paper towels. Water temperature in this bathroom#1 was measured at 132.5 degrees F and Bathroom #2 was measured at 132.6 degrees F which is in not between the required 105 – 120 degrees Regulations.

Operational Requirements:



Fire clearance was approved by LA County Fire Department for four (4) non-ambulatory and 1 bedridden. Approved Hospice Wavier for 2. Liability Insurance is confirmed and currently on file.

Resident Rights/Information:

Residential Care Facility for the Elderly Complaint Poster (PUB 475) posted on the wall. Residents’ Personal Rights posted on the wall. Facility provides internet access for residents.

Staffing:

A total of three (3) full-time staff members provides care and supervision to the residents.

Personnel Records/Staff Training:

Administrator’s certificate is active and effective through 02/14/2025. Four (4) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, employee rights, certifications, and 1st Aid/CPR training. Based on record review, LPA observed Staff #1 (S1) to Staff # 3 (S3) does not have valid 1st Aid Training in file.



Planned Activities:

Facility has sufficient space to accommodate indoor and outdoor activities that are easily accessible.

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

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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: HOUSE OF HOPE
FACILITY NUMBER: 198602272
VISIT DATE: 12/05/2024
NARRATIVE
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Incident Medical and Dental:

Residents are assisted with self-administration of prescription and non-prescription medications. Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to residents in care. Medications are given according to Physician directions. All residents have a Needs and Services Plan, and COVID-19 vaccination cards on file. Staff training was on file.

Resident Records/Incident Reports:

Four (4) resident files were reviewed containing admission agreements, Identification and Emergency Information, Physician's Report, medical/functional assessments, Appraisal/Needs and Services Plans, TB clearance, Pre-placement Appraisal, personal rights, and medication records. However, based on record review, LPA observed Resident # 2 (R2) negative TB test results not in file.

Disaster Preparedness, and Emergency Intervention:

A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. An emergency drill was conducted in 07/07/2024. No manual restraints or seclusion are used with residents in care.

Residents with Special Health Needs:



The facility is free from odors of incontinence. Currently, one (1) resident is on hospice care and one (1) resident is on home health. Bed rails for mobility assistance were observed in some resident beds but no physician order R2's files.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator Viviana Reynaga.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/05/2024 04:19 PM - It Cannot Be Edited


Created By: Daniel Konishi On 12/05/2024 at 03:43 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: HOUSE OF HOPE
FACILITY NUMBER: 198602272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(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 resident’s restroom #1 water temperature read at 132.5 degrees F and resident’s restroom #2 water temperature read at 135.6 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: 12/06/2024
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 LPA 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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2024 04:19 PM - It Cannot Be Edited


Created By: Daniel Konishi On 12/05/2024 at 03:47 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: HOUSE OF HOPE
FACILITY NUMBER: 198602272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed that Resident # 2 (R2) has bedrail beds but does not have any physician’s order in file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Administrator agrees to obtain and submit a physician’s order to the LPA for the R2’s bedrails. The order will specify the length of the bedrail approved for.
Type B
Section Cited
CCR
87458(b)(1)
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious disease or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA Konishi observed Resident #2 (R2) negative TB test results not in file.
POC Due Date: 12/19/2024
Plan of Correction
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Admninistrator will send R2's negative TB test results to the LPA by the POC due date.
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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/05/2024 04:19 PM - It Cannot Be Edited


Created By: Daniel Konishi On 12/05/2024 at 04:06 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: HOUSE OF HOPE
FACILITY NUMBER: 198602272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above and Staff #1 (S1) to Staff #3 (S3) did not have valid first aid training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Administrator will email S1 to S3's valid first aid training certificate to LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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