198602557-9-7-2022-28-AS-KLOG-CJ2RAT-20220907125141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602557
Report Date: 09/07/2022
Date Signed: 09/07/2022 12:51:50 PM

Document Has Been Signed on 09/07/2022 12:51 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALONDRA GUEST HOME		FACILITY NUMBER:	198602557
ADMINISTRATOR:	VILLAFLORES, LOURDES		FACILITY TYPE:	740
ADDRESS:	11849 ALONDRA BLVD		TELEPHONE:	(562) 863-7630
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 5	DATE:	09/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lourdes Villaflores (Administrator)		TIME COMPLETED:	01:00 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 Lourdes Villaflores (Administrator) and explained the purpose of the visit. The facility is licensed to serve: AGE RANGE 60 AND OVER. 6 AMBULATORY, OF WHICH 4 MAY BE NON-AMBULATORY. HOSPICE WAIVER FOR 1. The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, attached garage/storage, 3 resident bedrooms, 3 staff bedroom, 3 bathrooms. During today's visit, LPA observed the following: Facility is not operating over-capacity or beyond any conditions and limitation on the license. No pools and bodies of water on the premises. All outdoor and indoor passageways is kept free of obstruction. There is a presence of grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid mats or strips. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Criminal Record Clearance for all required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Licensee has obtained and kept on file documentation of a medical assessment, signed by a physician. Employees of CCLD is allowed to enter the facility to conduct inspections. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Centrally stored medicines is kept in a safe and locked place. LPA observed a bed, microwave, toaster in the garage which Administrator stated is for use as a staff bedroom. Facility was unable to provide an approved fire clearance or permit to convert the garage into a bedroom. Hot water temperature measured at 121.8 degrees F in bathroom #1. 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 Lourdes Villaflores.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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 09/07/2022 12:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALONDRA GUEST HOME	FACILITY NUMBER: 198602557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

This requirement is not met as evidenced by: LPA observed a bed, microwave, toaster in the garage which Administrator stated is for use as a staff bedroom. Facility was unable to provide an approved fire clearance or permit to convert the garage into a bedroom.
	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: 09/08/2022
	Plan of Correction
1 2 3 4	Licensee shall immediately remove the bed, unplug the microwave and toaster and stop the usage of the garage as a staff bedroom. Licensee shall provided proof to the department by the POC date.

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: Hot water temperature measured at 121.8 degrees F in bathroom #1.
	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: 09/08/2022
	Plan of Correction
1 2 3 4	Licensee shall immediately adjust water temperature to measure within Title 22 guidelines and provided proof to the department by the POC 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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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