198602557-8-10-2023-28-AS-EZAA-CUKR78-20230810124556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602557
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:46:17 PM

Document Has Been Signed on 08/10/2023 12:46 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
GREATER LA AC/SC, 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:	08/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Jaime Flores - Caregiver		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) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Jaime Villaflores who is a Caregiver and Assistant Administrator of the facility. The administrator Joy Villaflores arrived shortly thereafter. There are five (5) residents who reside within the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. Administrator advised she will send a completed Infection Control Plan within 7 days.

Physical Plant/Environment Safety:

· The facility is a single-story house located in a residential neighborhood. It is licensed for a capacity of six (6) residents, four (4) of which may be non-ambulatory and they also have a hospice waiver for one (1). It five (5) client rooms, a dining room, a kitchen, a private restroom (R1) connected with Bedroom #5 whose hot water temperature measured at 113.5 Degrees F, and a shared client Restroom (R2) whose hot water temperature measured at 115.8 Degrees F, a front and back yard patio area which held a storage shed and the facility’s washing and drying machines, and an attached garage which held the facility’s emergency food supply and cleaning supplies.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has one (1) fully charged fire extinguisher located near the kitchen of the facility.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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 08/10/2023 12:46 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
GREATER LA AC/SC, 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: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff members because 2 staff member's CPR/AED/First Aid Training certificates expired on 2/7/2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that CPR/First Aid certificates for all staff members will be kept up-to-date at all times. Administrator is to provide LPA photogrpahic proof that the 2 staff members have updated the CPR/First Aid training by 9/7/2023.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALONDRA GUEST HOME	FACILITY NUMBER: 198602557
	VISIT DATE: 08/10/2023

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
26
27
28
29
30
31
32

· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) residents, four (4) of whom may be non-ambulatory and a hospice waiver approved for one (1).

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of eight (8) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training, however the 1st Aid/CPR training is out of date and expired on 2/7/2023 for 2 staff members.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALONDRA GUEST HOME	FACILITY NUMBER: 198602557
	VISIT DATE: 08/10/2023

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
26
27
28
29
30
31
32

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

· No restricted Health Care plan required for the clients in the facility.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4