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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602531
Report Date: 09/07/2023
Date Signed: 09/08/2023 08:18:58 AM

Document Has Been Signed on 09/08/2023 08:18 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:MYRABEL VITANGCOLFACILITY TYPE:
735
ADDRESS:3037 EAST MERRYGROVE STREETTELEPHONE:
(626) 612-7318
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Milagros Francisco TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Lead Staff, Milagros Francisco, who allowed entry into the facility and assisted with the visit.

LPA and Ms. Francisco toured the facility inside and out, reviewed food supply, reviewed staff files, reviewed resident files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. Carbon monoxide detector was also observed, tested and operational. LPA observed a sufficient supply of PPE. LPA observed a sufficient amount of perishable and non-perishable food on today's visit.

LPA reviewed 4 client files and 4 staff files. LPA observed needs and services plans, admission agreements, physicians reports with TB test results, as well as other required documents.

Deficiencies cited on 809-D.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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 09/08/2023 08:18 AM - It Cannot Be Edited


Created By: Angelica Rea On 09/07/2023 at 11:00 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: 09/07/2023

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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LPA Rea observed that water temperature in bathroom(s), measured at 134.9 degrees F and 135.2 degrees F.
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 water faucets/sinks measured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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Administrator will ensure that water temperature in all sinks measures between 105 degrees F and 120 degrees F. Administrator will send a log to LPA with water temperature readings for 5 days, showing that water temperature has been corrected.
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:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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