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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602936
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:34:33 PM

Document Has Been Signed on 10/08/2024 04:34 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/
DIRECTOR:		TILLMAN, GREGFACILITY TYPE:
740
ADDRESS:128 N FOURTH STREETTELEPHONE:
(626) 863-6349
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 15CENSUS: 11DATE:
10/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:57 PM
MET WITH:Rosalie Ngo and Greg Tillman - Administrators TIME VISIT/
INSPECTION COMPLETED:
04:38 PM
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to complete annual inspection. LPA met with Licensee Rosalie Ngo and Administrator Greg Tilman arrived a short time later. LPA discussed purpose of visit.

Today LPA inspected the remaining domains using the CARE tool.


Staffing:
There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no deficiencies observed. Administrator Greg Tillman certificate expires on 10/09/2024. Administrator has applied for renewal.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the entrance.

A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.

Currently facility has one (1) hospice resident and has waiver for two (2)

(continued on (809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MY LADIES GUEST HOUSE
FACILITY NUMBER: 198602936
VISIT DATE: 10/08/2024
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(Continued from 809C)

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

Incident Medical and Dental:

Five (5) centrally stored resident medications were reviewed. Medication is given according to doctor’s orders. Medical and dental transportation is provided by family, and transportation services.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. LIC610 needs to be updated when all staff are trained on shut of utilities.



Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files.
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No deficiencies were cited today. Technical advisory provided.

Exit interview was conducted with staff. A copy of the report, technical advisory and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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