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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603327
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:26:55 PM

Document Has Been Signed on 08/02/2024 12:26 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:R PLACE DUARTEFACILITY NUMBER:
198603327
ADMINISTRATOR/
DIRECTOR:		RISINGER, ROBERTFACILITY TYPE:
735
ADDRESS:3002 FREEBORN STREETTELEPHONE:
(626) 609-7159
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 1DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Robert Risinger - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Robert Risinger, Administrator and Claudia Renteria, Care Staff and explained the purpose of today's visit. The facility is approved for capacity of (6) non ambulatory age range 18 through 59 of which (1) may be bedridden; bedridden to reside in Room #5. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan.
Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room, (4) client bedrooms, (1) office, (4.5) bathrooms, laundry area, indoor/outdoor activity space, attached garage, and a shaded patio with seating. Currently, there is (1) client residing in the home. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is in the hallway. The fire extinguisher near the exit door towards the backyard had an expired receipt of 08/09/2020 and the other fire extinguisher mounted on the wall in the dining area was expired, purchased on 10/01/2022. Knives, cleaning solutions, and disinfectants are locked and inaccessible to client. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 113 deg F in bathroom #1, 113.3 deg F in bathroom #2 and 115.3 deg F in bathroom #3. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. There is camera in the front/back yards and common areas.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid. Per the designated Administrator, the last Fire Drill was conducted recently. *****Refer to LIC 809C for the continuation of this report.*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: R PLACE DUARTE
FACILITY NUMBER: 198603327
VISIT DATE: 08/02/2024
NARRATIVE
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Staffing: A total of three (3) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator certificate is valid and expired on 06/10/2024, but presented proof that renewal was sent to CDSS on 4/12/2024. Administrator has valid HIV/AIDS Training certificate.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (2) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Administrator's first aid/CPR training certificate expired on 03/05/2022 and has not received training in first aid/CPR since.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the client.
Client Records-Incident Reports: LPA reviewed (1) client file. Client file is maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked in a cabinet under the kitchen sink).
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. However, Administrator signed/initialed evening/bedtime doses of one of the client’s medication on the Medication Administration Record (MAR) for 8/02/2024, although the medication has not been administered yet
Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D and Technical Assistance issued. Exit interview, appeals rights and a copy of this report was provided to Administrator, Robert Risinger.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/02/2024 12:26 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/02/2024 at 12:04 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: R PLACE DUARTE
FACILITY NUMBER: 198603327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator/ licensee did not comply with the section cited above in that the fire extinguisher near the exit door towards the backyard had an expired receipt of 08/09/2020 and the other fire extinguisher mounted on the wall in the dining area was expired, purchased on 10/01/2022 which poses an immediate health, safety or personal rights risk to client in care.
POC Due Date: 08/05/2024
Plan of Correction
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Administrator/licensee agreed to purchase a new fire extinguisher(s) and keep a copy of receipt to show purchase date for future inspections and submit a copy of the receipt to CCL/LPA by POC due date,
Type A
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator/ licensee did not comply with the section cited above in that the Administrator/licensee signed/initialed evening/bedtime doses of the client’s medication Quetiapine 100 mg on the Medication Administration Record (MAR) for 8/02/2024, although the medication has not been administered yet which poses an immediate health, safety or personal rights risk to client in care.
POC Due Date: 08/05/2024
Plan of Correction
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Administrator/licensee will ensure medication provided to the client is on cycle and recorded properly by staff on Medication Administration Record (MAR) sheet and re-train staff on medication. Proof of training along with the topics discussed, signed and dated by staff shall be submitted to CCL/LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/02/2024 12:26 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/02/2024 at 12:04 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: R PLACE DUARTE
FACILITY NUMBER: 198603327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, record review, the Administrator/licensee did not comply with the section cited above in that
Administrator's first aid/CPR training certificate expired on 03/05/2022 and has not received a current training yet which poses/posed a potential health, safety or personal rights risk to client in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator/licensee will submit a current/valid first aid/CPR training certificate to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
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