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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603035
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:53:38 PM

Document Has Been Signed on 09/20/2022 03:53 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:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:YASHICA MORROWFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
09/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 AM
MET WITH:Aniema Aktanudosen,TIME COMPLETED:
03:15 PM
NARRATIVE
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On the above date, Licensing Program Analyst (LPA) Christine Wong conducted a 24 hours health and safety check for the above facility regarding to the complaint - 28-AS-20220920102820. During the visit, LPA toured the facility and observed the hot water temperature measured at two bathrooms were between 92.1 and 104 degrees F which is below the required 105 - 120 degrees.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to House Lead Aniema Aktanudosen,
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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 09/20/2022 03:53 PM - It Cannot Be Edited


Created By: Christine Wong On 09/20/2022 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PUENTE HOME
FACILITY NUMBER: 198603035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2022
Section Cited
CCR
800889(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1)Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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The administrator will fix the hot water temperature in both bathrooms immediately and will send the 7 days hot water log via email to LPA by 9/27/22.
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The requirement is not met as evidenced by LPA's observation- LPA measured both bathrooms' hot water temperature in the facility, they were tested between 92.1 and 95 degrees which posed an immediate risk to the clients in care.
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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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022


LIC809 (FAS) - (06/04)
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