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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602531
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:54:30 AM

Document Has Been Signed on 10/27/2021 11:54 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:CALVITACARE1 CORPFACILITY NUMBER:
198602531
ADMINISTRATOR:VITANGCOL, FLORENTINOFACILITY TYPE:
735
ADDRESS:3037 EAST MERRYGROVE STREETTELEPHONE:
(909) 612-7318
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Milagros Fransisco, Staff TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Milagros Fransisco and explained the purpose of the visit. Licensee Florentino Vitangcol and Administrator Myrabel Vitangcol were explained the purpose of today's visit telephonically. There are four (4) level 4C ambulatory developmentally disabled clients ages 18-59 in the home. The facility is a single story home located in a residential neighborhood that is licensed for 4 ambulatory only clients. It consists of 4 client bedrooms, living room, dining room, kitchen, 2 bathrooms, backyard patio area, and attached garage. The last fire drill was conducted on 8/10/2021. Administrator certificate expires 8/27/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, bathrooms and reside rooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • Four (4) centrally stored resident medication records were reviewed.
  • Staff were observed wearing mask.
  • Client's wear masks in the home, except during meal times.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • Client rooms #2 and #3 had holes in the walls.
  • Both outdoor side gates had locking mechanisms. Staff was not able to open them at first, and later found the key to the right side gate door. The left side iron gate's door handle is broken and hard to open.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with staff Milagros Fransisco. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/27/2021 11:54 AM - It Cannot Be Edited


Created By: Noemi Galarza On 10/27/2021 at 11:04 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: CALVITACARE1 CORP
FACILITY NUMBER: 198602531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during physical plant inspection the licensee did not comply with the section cited above in that client room #2 and client room #3 had holes on the walls that have not been repaired. Room #2's closet door had a hole in the closet door which poses/posed a potential health, safety or personal rights risk to persons in care. Pictures were taken.
POC Due Date: 11/17/2021
Plan of Correction
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Administrator agrees to repair by POC due date the following:
1. Repair the holes in room #2 and paint the dry wall that was repaired.
2. Repair holes in room #3.
Submit picture proof evidence of repair completion.

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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2021 11:54 AM - It Cannot Be Edited


Created By: Noemi Galarza On 10/27/2021 at 11:12 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: CALVITACARE1 CORP
FACILITY NUMBER: 198602531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(7)
Personal Rights. Each client has the right not to be locked in any room, building, or facility premises by day or night.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during outdoor physical plant inspection at 10:40 AM, the licensee did not comply with the section cited above in that LPA observed both right and left side iron gates had locking mechanisms that does not enable clients to exit/open the door from the interior side of the gate which poses an immediate health, safety or personal rights risk to persons in care. Staff was not able to open them at first and later found the key to the right side gate door. The left side iron gate's door handle is broken and hard to open. Left side door needs repair.
POC Due Date: 10/28/2021
Plan of Correction
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Administrator shall ensure that all exit gates are able to be opened from the interior of the facility. No locking mechanism that require a key shall be placed in exterior exit doors. Submit picture proof and a written statement stating that both red and chain link locking mechansims have been removed and will not be in use.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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