198602890-6-18-2024-28-AS-NGAA-D6CRTA-20240618131800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602890
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:18:11 PM

Document Has Been Signed on 06/18/2024 01:18 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 LOVE		FACILITY NUMBER:	198602890
ADMINISTRATOR:	WISE, CHANTE		FACILITY TYPE:	740
ADDRESS:	12121 164TH STREET		TELEPHONE:	(562) 229-9957
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Jing Struve		TIME COMPLETED:	01:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to caregiver staff and telephonically to Administrator Cherie Wood. Licensee/former Administrator Chante Wise was contacted regarding the pending application for a change of ownership. Ms. Wise stated that Applicant Jing Struve took over facility operations on 10/16/2023. Ms. Jing Struve arrived later. There are currently 4 elderly residents 60 years and older residing in the facility. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

Infection Control:

The facility has an Infection Control Plan. A visitor sign-in sheet is in place.

Operational Requirements:

An Infection Control Plan has been added to the Plan of Operation.
The facility has a Dementia Waiver in place and an approved Hospice Waiver for 3 residents.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/31/2024.
A surety bond is not applicable. Facility does not handle resident's money.
Facility has an American Red Cross 1st Aid kit and manual.

*Narrative continues next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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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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
	VISIT DATE: 06/18/2024

NARRATIVE

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Physical Plant/Environment Safety:

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 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 underneath kitchen cabinet containing cleaning products was unlocked.
The auditory alarms on all exit doors are not operable. *There is a resident with a Dementia diagnosis.
The facility has one (1) fully charged fire extinguisher.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

A total of 3 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificates expired 10/8/2023. Cherie Wood is the current Administrator, but Licensee has not submitted change of Administrator documents to CCL.
Personnel files/training were reviewed. Proof of staff training and health clearance/TB screening was missing from staff files. Criminal background clearance and 1st Aid/CPR training were verified.

Resident Records/Incident Reports:

A total of four (4) resident files were reviewed; they contained admission agreements, Physician's Reports, TB clearance, Physician's Orders, medical consent, and medication records . Residents (R1- R3) did not have pre-placement, resident appraisals on file. Hospice resident (R2) did not have Appraisal Needs/Services Plans on file.
RCFE complaint poster and Personal rights are posted.

***Narrative continues next page***

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 06/18/2024

NARRATIVE

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Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Activities are individualized.
The facility does not have a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Two (2) residents have a physician order for a modified diet.

Incident Medical and Dental:

Four (4) centrally stored resident medications were reviewed to verify there is a 30-day supply of medications.
Medical and dental transportation is provided by families.

Disaster Preparedness:

The emergency disaster plan was reviewed.
The last disaster drill logs was conducted on 4/1/2024, within the required quarterly basis.

Residents with Special Health Needs:

One (1) resident receives hospice services. One (1) resident receives home health services.
Postural support physician orders were not observed in all resident files. Full and half bed rails for mobility assistance were observed in all resident rooms. No residents have prohibited health conditions.
Hospice resident (R2's) file did not contain any appraisals.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Ms.Jing Struve. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2024 01:18 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the cabinet under the kitchen sink and bathroom sink were unlocked with cleaning supplies; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to a written plan of correction by tomorrow and on 6/13/24 submit proof of staff in-service training regarding Title 22 regulation 87705.

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that none of the exit doors had working auditory alarms; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Administrator shal submit: 1. Proof that the auditory alarm on all exit doors are operable 2. A written plan of correction that addresses the plan of correction/staff in-service training.

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	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2024 01:18 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 above in that staff files only had 1st Aid/CPR training, but no other training documents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof of all staff training in-services, that include staff signatures.

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 that residents (R1-R3) do not have pre-placement and/or resident appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Administrator shall submit copies of resident (R1- R3’s) Appraisal Needs and Services Plans.

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	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2024 01:18 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87407(k)(1)

Administrator Recertification Requirements Personnel Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office ..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Administrator/Licensee stopped working at the facility on 10/16/2023 and has not submitted change of Administrator notification to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit change of Administrator notification and required documents to CCL.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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