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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602890
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:14:03 PM


Document Has Been Signed on 06/29/2022 12:14 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:J AND C HOUSE OF LOVEFACILITY NUMBER:
198602890
ADMINISTRATOR:WISE, CHANTEFACILITY TYPE:
740
ADDRESS:12121 164TH STREETTELEPHONE:
(562) 229-9957
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 6DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Chante Wise Smith, AdministratorTIME COMPLETED:
12:20 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 staff Katherine Camarena and explained the purpose of the visit. Administrator Chante Smith arrived shortly after. There are 6 residents ages 60 and above. The facility has a Dementia waiver, and a hospice waiver for 3 residents. Facility is a single story home located in a residential area consisting of 4 resident bedrooms, 1 live-in staff bedroom, 4 bathrooms, living room/dining area, kitchen, outdoor covered patio area, laundry room, and a detached garage. The last emergency disaster drill was conducted on 6/23/2022. Administrator certificate expires 10/8/2023.

The following was inspected and observed during the inspection:
  • The interior and exterior physical plant was inspected.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical
  • distancing. Facility has an approved COVID-19 mitigation plan. LPA was screened upon entry by staff.
  • Room # 4 is designated as the COVID-19 isolation room if needed.
  • Six (6) centrally stored resident medication records were reviewed.
  • Due to cognitive impairment residents in care do not wear masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Bedridden room #4 had an inoperable auditory alarm on the door, and the alarm in the front door is operable, but the door is kept opened by staff for ventilation. Licensee stated she will install an additional auditory alarm on the front door metal screen door.


Deficiencies were cited. See LIC 809D.

Exit interview was held with Administrator Chante Smith . A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 06/29/2022 12:14 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: J AND C HOUSE OF LOVE
FACILITY NUMBER: 198602890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia.
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 in that bedridden room #4 had an inoperable auditory alarm, and the alarm in the front door is operable, but the door is kept opened by staff; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Administrator shall ensure that all auditory devices on the exit doors and windows are turned on, and operable at all times. Administrator agreed to submit a written statement and proof of staff training by tomorrow's POC due date.
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: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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