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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602638
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:08:04 PM


Document Has Been Signed on 07/11/2023 03:08 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:D & L RESIDENTIAL CARE HOME 1FACILITY NUMBER:
198602638
ADMINISTRATOR:RAFAEL DIAZFACILITY TYPE:
740
ADDRESS:330 WEST CITRUS EDGE STREETTELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 6DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Olga Soto, Care Giver/House ManagerTIME COMPLETED:
03:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Olga Soto and explained the purpose of the visit. The facility is licensed to serve 6 residents 60 years and older. Five (5) can be non-ambulatory and One (1) Bedridden, facility has hospice waiver for two (2). LPA use the CARE tool for this visit.

LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff were still cleaning and disinfecting throughout the day. Sufficient PPE supplies and. Facility does not have an Infection Control Plan posted by the entrance.
Physical Plant & Environment Safety: The 1-story facility is in good repair. Fire and carbon monoxide detectors are in every room. One smoke detector the hallway is not working. The 1-story facility consist of the following: 4 rooms, attached garage, 1 kitchen, 2 bathrooms, Facility has one screen in disrepair.
Operational Requirements: The facility did not have plan on file to accept or retain residents with dementia on file. The facility does not have current liability insurance covering injury to residents and guest on file. Staff employed are all over the age of 18.
Staffing: There appears to be sufficient staffing at the facility. The administrator’ Rafael Diaz did not have certificate on file and the ones posted had other names and are expired. .
Personnel Records-Training: Staff files are not maintained at the facility. All staff have current CPR/first aid training and but no evidence of on-going training

(Continued on 809C)

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water measured 144.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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Caregiver adjusted the water at time of visit. ***No further action is required****
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility did not have plan of operation on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will send plan of operation to LPA by POC date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility did not have evidence of liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will provide proof of liability insurance to LPA by 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One smoke alarm needs replacement, small oven on counter is not functioning and needs to be discarded. Outside umbrella for shade needs to be repaired or replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will replace smoke alarm, discard small oven, repair or replace outside umbrella and send proof to LPA by POC date.
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above. No staff have current training in facility emergency procedures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will conduct training on emergency procedures and send proof to LPA by POC.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. No resident has appraisal or reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will provide pre-admission appraisal and reappraisals and for all clients and send to LPA by POC
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LET US KNOW and personal rights poster is not posted at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will post a LET US KNOW and personal rights poster and send proof to LPA by 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above facility had no documentation that personal rights training was conducted with staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will provide training on personal rights and send proof to LPA by POC date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above 4 of 5 residents did not have labels on over the counter or PRN which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will obtained labels for all PRN and over the counter medications and send proof to LPA by 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 03:08 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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above All resident files are missing PRN authorization letters which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will obtain PRN authorization letters for all PRN and over the counter medication and send proof to LPA by POC date.
Type B
Section Cited
HSC
1569.695(a)(6)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (6) The location of utility shut-off valves and instructions for use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Staff are not trained in how to shut off gas or other utilities which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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Administrator will provide instructions to staff on how to turn off utilities and provided proof to LPA by 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


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: D & L RESIDENTIAL CARE HOME 1
FACILITY NUMBER: 198602638
VISIT DATE: 07/11/2023
NARRATIVE
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Resident Rights-Information: The facility has internet access and facility has device for residents to use. No personal rights are posted at facility.
Resident Records-Incident Reports: Resident files are maintained at the facility and do have the following documents in their files - Admission Agreements, Face sheet and other required documentation. All clients have overdue Physician’s report and needs and services plan.
Food Service: Facility has supply of 2 day perishable food and 7 days of non-perishable food at facility.
Health-Related Services:. Labels and PRN letters are missing from resident files.
Incidental Medical Services: LPA reviewed 6 client medication files. Medications are administered according to doctor’s orders.
Disaster Preparedness: The facility does have up to date Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Facility has plan for emergency intervention.

Civil penalties issued for repeat violation within 12 months.

Deficiencies sited (See 809D) and technical advisory was also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory note, and appeal rights were given to House Manger Olga Soto

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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