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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:47:39 PM


Document Has Been Signed on 10/13/2022 04:47 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:MY LADIES GUEST HOUSEFACILITY NUMBER:
198602936
ADMINISTRATOR:TILLMAN, GREGFACILITY TYPE:
740
ADDRESS:128 N FOURTH STREETTELEPHONE:
(626) 863-6349
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:15CENSUS: 7DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Greg Tillman, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA met with the Administrator, Greg Tillman. The purpose of the visit was explained. The facility is approved for 15 residents, ages 60 and over, of which 15 may be non-ambulatory.
This facility has a total of 10 bedrooms and 3 communal bathrooms downstairs. Rooms #1 - #6 are either single or shared rooms and Rooms #7 - #10 are all single bedrooms with a private bathroom. The Administrator's office is on the second floor.

LPA toured the facility, interviewed 3 Staff, and 2 Residents. The following were inspected/observed:
* Signage are posted by the front entrance and throughout the facility to promote hand washing, cough etiquette, and social distancing.
* Table is set up by the entrance where the visitor sign in, screened, and temperature taken. Masks and hand sanitizers are readily available.
* There are vacant rooms which can be utilized as isolation rooms for COVID-19 positive residents.
* Extra supplies of PPE such as N95 masks, hand sanitizers, and gowns are stored in the garage.
* Disinfectant and cleaning supplies are stored and locked under the kitchen sink. Extra supplies are stored in the supply closet.
* There are adequate food supplies of 2 day perishable and a week of non-perishable observed.
* Reviewed medications for 4 residents and medications are being given as prescribed.
* LPA reviewed 3 Staff files and 4 Resident files today. Staff #1, #2, and #3 files did not have current First aid training certificates.

A deficiency is cited on the LIC809D. An exit interview was conducted and a copy of this report along with appeal rights were provided to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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 10/13/2022 04:47 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: MY LADIES GUEST HOUSE
FACILITY NUMBER: 198602936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(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
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff which poses a potential health, safety risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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The administrator shall ensure that the staff have current first aid training in their files. The administrator shall schedule First Aid training for Staff #1-#3 by POC due date 10/31/2022.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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