<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603174
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:55:25 PM

Document Has Been Signed on 09/29/2023 01:55 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:ALVARADO CARE HOMEFACILITY NUMBER:
198603174
ADMINISTRATOR:DUNGCA, ROMMELFACILITY TYPE:
735
ADDRESS:1217 S ALVARADO STREETTELEPHONE:
(562) 505-6484
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 46CENSUS: 40DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Doris Elicanal - Case ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Case Manager Dorisel Elicanal and Administrator Rommel Dungca who later assisted with the visit. The purpose for today’s visit was explained.

The 2-Story facility is located in Los Angeles CA, and licensed to serve 30 Ambulatory and 16 Non-Ambulatory clients ages 18-59 (16 may be bedridden on first floor only).

A tour of the facility includes: First Floor: front desk office, lobby, living room, dining area, patio, kitchen with pantry, laundry room, 1 visitor restroom, 2 staff office, laundry room, medication room, 2 storage closets, elevator and 8 shared client bedrooms with shared bathrooms. Second Floor: Elevator, storage closet, staff lounge “resting room”, 1 staff bathroom, laundry closet, 2 offices used as storage rooms, 1 staff office, and 15 shared client bedrooms with shared bathrooms.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility has a valid Infection Control Plan and have sufficient PPE supplies.


Physical Plant & Environment Safety: LPA toured 6 clients’ bedrooms and closet/drawer space to accommodate each client comfortably was available. Hygiene products are readily available for clients in care. The hot water temperature was measured throughout the facilities client bathrooms and were within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are centrally stored and kept locked and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There is an emergency sprinkler system throughout the facility. The fire extinguishers were observed and are fully charged.
(Continued on 809C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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 4
Document Has Been Signed on 09/29/2023 01:55 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/29/2023 at 12:37 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: ALVARADO CARE HOME
FACILITY NUMBER: 198603174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation/interview/record review, the licensee did not comply with the section cited above as the last fire/earthquake/emergency drill was conducted on 12/19/22, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
1
2
3
4
Licensee has planned to conduct a fire/earthquake/emergency drill prior to POC due date and will submit log with all who attended training/drill to LPA via email by POC due.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation/staff record review, the licensee did not comply with the section cited above in 1 out of 5 staff files that were reviewed did not have proper First Aid / CPR training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
1
2
3
4
Licensee will have staff trained on First Aid/ CPR prior to POC due date and will submit copy of training to LPA via email once training is complete.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/29/2023 01:55 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/29/2023 at 12:37 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: ALVARADO CARE HOME
FACILITY NUMBER: 198603174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 as there was no evacuation chair at either of the 2 stairwells within the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
1
2
3
4
Licensee stated will order 2 evacuation chairs to comply with this regulation and will submit proof by photos and receipt to LPA via email by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ALVARADO CARE HOME
FACILITY NUMBER: 198603174
VISIT DATE: 09/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Operational Requirements: The facility has the proper fire clearance on file. Last fire/earthquake/emergency drill was conducted on 12/19/22 (details will be documented on 809D). There is an outdoor activity area that is furnished for outdoor use.
Staffing: There seems to be sufficient staffing at all times with at least one night supervision staff on duty at all times.
Personnel Records-Training: Staff have the proper criminal and background clearance. LPA reviewed 5 staff files and 1 out of the 5 did not have CPR/First Aid training on file (details will be documented on 809D). All other ongoing training was documented. Administrator Rommel Dungca is currently pending renewal for administrator certificate, current certificate expired 7/1/23 and CLL received renewal on 5/30/23.
Client Rights-Information: Facility provides both telephone and internet for clients in care.
Client Records-Incident Reports: Client Files are securely stored within the locked medication room on the first floor and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply with no issues.
Health Related Service: All medications are centrally stored in Medication Room and are properly labelled and in their original containers. LPA reviewed 6 clients medications with no issues.
Incidental Medical & Dental: Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Facility did not have evacuation chairs at stairwells (details will be documented on 809D).
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA Interviewed 5 Clients / 3 Staff and reviewed 5 staff / 5 resident files during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D).

Exit interview was held and a copy of the report was provided to Administrator Rommel Dungca.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4