198603189-10-20-2021-28-AS-BTAO-C7YU8U-20211020152207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603189
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:22:22 PM

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:	MAISON DE FLEURS		FACILITY NUMBER:	198603189
ADMINISTRATOR:	PAGANOS, GEORGE		FACILITY TYPE:	740
ADDRESS:	4918 N SUNFLOWER AVE		TELEPHONE:	(714) 606-1854
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 4	DATE:	10/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ralph Estanislao, Administrator Assistant Alicia Tongol, Staff		TIME COMPLETED:	03:30 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) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant, and Alicia Tongol, Staff. LPA explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and three (3) hospice waivers. Current resident census is four (4). Two (2) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. This home is a single story house located in a residential neighborhood in Covina. The facility consisted of vaulted ceilings with three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard. No garage. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Stove tops are in working condition. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAISON DE FLEURS	FACILITY NUMBER: 198603189
	VISIT DATE: 10/20/2021

NARRATIVE

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Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature of 73 degrees Fahrenheit for residents.

Deficiency is cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAISON DE FLEURS	FACILITY NUMBER: 198603189
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Medication is not locked and accessible to residents. The lock key remains inserted in the lock during the entire visit.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2021
	Plan of Correction
1 2 3 4	Administrator ensures the key in the medication cabinet is removed when the cabinet is locked. A key chain will be use to keep the key. Due date 10/21/21. Administrator will provide in service training to staff by 10/25/21.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC809 (FAS) - (06/04)

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