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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603126
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:35:12 PM


Document Has Been Signed on 07/27/2023 03:35 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:ANL FACILITY HOME INCFACILITY NUMBER:
198603126
ADMINISTRATOR:BULOSAN, LUZVIMINDA AFACILITY TYPE:
740
ADDRESS:12073 HIGHDALE STTELEPHONE:
(562) 310-4871
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Luzviminda BulosanTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Luzviminda Bulosan and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Administrator Luzviminda Bulosan today 07/27/2023 at 1:00 PM and the following was observed
Facility contains 4 Resident Bedrooms and 2 client bathrooms dining room, kitchen, and TV room.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/ Information, Food Service, Planned Activities, Health Related Services, Incidental Medical and Dental, Disaster Preparedness and Resident's with Special Health Needs.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed and was given per physician's directions.
3 Resident Files and 5 Staff Files were reviewed.
Interviews were conducted with 2 Staff and 4 Residents.
In Bedroom 3 resident had full bed rails and was not on Hospice.
Physician's Report for Dementia resident was last done 06/14/2022 over 1 year ago.
Deficiencies cited on 809 D. Exit interview conducted and copy provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/27/2023 03:35 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: ANL FACILITY HOME INC
FACILITY NUMBER: 198603126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)


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 with 1 Resident with Dementia not having a medical assessment done annually with the last one done 06/14/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Facility to submit medical assessment by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/27/2023 03:35 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: ANL FACILITY HOME INC
FACILITY NUMBER: 198603126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(5)(B)


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 with 1 resident not on Hospice having full bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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2
3
4
Facility to remove full bed rails by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3