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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603276
Report Date: 09/12/2022
Date Signed: 09/12/2022 12:56:39 PM


Document Has Been Signed on 09/12/2022 12:56 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:YEARLING BOARD AND CAREFACILITY NUMBER:
198603276
ADMINISTRATOR:TANGONAN, MARIA ISABELFACILITY TYPE:
740
ADDRESS:11439 YEARLING CIRCLETELEPHONE:
(562) 307-7668
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 4DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leonida Namaug & Modesto Valentos- StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the required 1 year inspection. LPA was greeted by caregiver Modesto Valentos and he was explained the purpose for the visit. Modesto phoned licensee Maria Tangonan and informed her of the visit. Shortly after, licensee's aunt Leonida Namuag arrived at the facility to assist with the inspection. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with caregiver Modesto and Leonida, food and PPE supplies were observed, and COVID-19 procedures and residents' medications were reviewed. Licensee Maria Tangonan arrived at the end of the visit to assist with the visit.

The facility is a one story home in a residential area that consists of 5 bedrooms, 3 bathrooms, a living room, a kitchen, a dining room, a back patio, and attached garage. The facility is licensed to serve 6 non-ambulatory residents, of which 1 may be bedridden, all of ages 60 and over. The facility also has a hospice waiver for 6 residents. During the tour, LPA observed the living room area with sufficient seating and lighting. Social distancing signs were posted throughout the facility. All 5 bedrooms were observed to have the required bedding, furniture and storage space. The 3 bathrooms were observed to have functional showers, toilets and wash basins. All handwash stations were fully stocked with soap and paper towels for use. The hot water was tested in all bathrooms and measured within the required 105*F - 120*F. All showers were observed to have the required grab bars and non-skid mats. The food supplies was observed in the kitchen and the emergency food supplies was stored in the garage. LPA observed more than the required 2-day perishable and 7-day non-perishable food supplies. All sharps were observed to be stored and locked in a kitchen cabinet next to the sink, and cleaning supplies and toxins were stored and locked under the kitchen sink. The back patio had a shaded seating area for the residents. All walkways and entrances/exits were observed to be clear and free of debris and hazards. A fire extinguisher was observed in the hallway and in the garage- both inspected and fully charged. Sufficient PPE was observed throughout the facility and readily available for resident use. Smoke/carbon monoxide detectors were tested and observed to operate properly. (Report Continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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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: YEARLING BOARD AND CARE
FACILITY NUMBER: 198603276
VISIT DATE: 09/12/2022
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At 11:02AM, LPA reviewed the medication for Residents#1-#4. R1-R3 had prescribed medications that were not properly labeled, per California Code of Regulations, Title 22.

At 11:30AM- LPA reviewed the facility staff roster and association list. During the review, it was discovered that (1) staff has a criminal background clearance, but is not associated to the facility.

Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D.

Additionally, immediate civil penalties in the amount of $500 will be issued today.

An exit interview was conducted with Licensee Maria Tangonan and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2022 12:56 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: YEARLING BOARD AND CARE
FACILITY NUMBER: 198603276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review… shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance…
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 staff having a criminal background clearance, but no association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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2
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4
Licensee will associate the staff in question to the facility via Guardian and provide a copy of the association list as proof. This will be emailed to LPA by the POC due date.
Type A
Section Cited
CCR
87465(e)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication…
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in3 of 4 residents having medications that are not properly labeled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee will label all resident medications accordingly and send pictures of the correction via email to LPA by the POC due date.

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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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