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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603206
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:45:02 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:LOVING ARMS RESIDENTIAL CARE FOR SENIORS IIFACILITY NUMBER:
198603206
ADMINISTRATOR:LI, CRYSTALFACILITY TYPE:
740
ADDRESS:11503 THOMAS PLTELEPHONE:
(408) 893-2746
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 3DATE:
11/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lourdes BisnarTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted a case management at the facility and met with Administrator Lourdes Bisnar to discuss the purpose for todays visit. During todays required 1 year visit, LPA observed that there were no staff present in the facility. LPA observed a physical therapist assisting resident #1. LPA Wesley contacted the Licensee Crystal Li via telephone who was attending an appointment in West Los Angeles and advise them of the situation with that no staff were present in the facility. During the phone conversation Emiliana Pangilinan Torres arrived from the facility next door and attempted to enter through the dining room door. It appears that staff Pangilinan did not understand what the LPA was saying so they asked staff Florinda Malig Ventenilla to come from next door and provide assistance. During the visit, Administrator Lourdes Bisnar arrived and joined the visit.

The following deficiency is cited in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8 is on the attached LIC 809D. Immediate civil penalties assessed(LIC 421BG). Appeal rights explained. A copy of the LIC 809, LIC 809D, civil penalty assessment and appeal rights were given during the exit interview.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS II
FACILITY NUMBER: 198603206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.....
This evidence has not been met as evidenced by
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LPA Wesley arrived to the faciilty to complete the Required 1 year visit and there was no staff present in the facility with 3 residents in care. This poses an immediate health, safety risk to the clients in care.
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Please list the training topics discussed and provide the in service training log with staff signatures by the POC due date 11/16/21.

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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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