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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 12/09/2023
Date Signed: 12/09/2023 04:37:15 PM


Document Has Been Signed on 12/09/2023 04:37 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:SUPERCARE GUEST HOMEFACILITY NUMBER:
198603358
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:13449 BIOLA AVETELEPHONE:
(714) 244-5885
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 6DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Caregiver- Jhonrev JimenezTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 12/09/2023.
LPA was met by Caregiver Jhonrev Jimenez and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4).

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of three (3) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard.

Front Yard: Front yard is well maintained, and no hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed one (1) knife a top kitchen countertop, next to a cutting board and veggies, to be accessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 124.3-degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, accessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed lower kitchen cabinet located next to stove to contain several dead insects.

Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 77 degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



Resident Rooms 1-3: LPA Ramirez inspected three (3) shared resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed auditory devices to be operable in all resident bedroom exits.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
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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Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, knife was observed a top kitchen countertop, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2023
Plan of Correction
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Staff secured knife during visit. Licensee will retrain staff on above regulation and send proof of staff receiving training by 12/16/23.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions and disinfectants were accessible in kitchen and bathroom#1, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2023
Plan of Correction
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Staff secured both cabinets during visit. Licensee will retrain staff on above regulation and send proof of staff receiving training by 12/16/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1 and S2 were missing health screeening, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit health screening by 12/16/23 and maintain in personnel records.
Type B
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S3 did not have proof of documented criminal record clearance or criminal record exepmtion,the licensee did not comply with the section cited above in 6 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit proof of clearance or exepmtion via email by 12/16/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 14


Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1, S3,S4,S5 did not have documented initial dementia training within 4 weeks of employment, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will review above regulation and certify via email understaning of regulation.

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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1 and S3, did not have documented annual training, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will conduct training on above regulation and send proof by 12/16/23.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R6 did not have required annual medical assessment, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit medical assessment by 12/16/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
Page: 5 of 14


Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R6 did not have medical assessment with TB results, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit medical assessemnt with TB results by 12/16/23.
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R6 did have medical assessment that indicated ambulatory status, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit medical assessment that indicated ambulatory status.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
Page: 6 of 14


Document Has Been Signed on 12/09/2023 04:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, several dead roaches were observed in lower kitchen cabinet near stove, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will provide pest control contract and keep facility free from insects. Licensee will clean out cabinet with dead insects.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R2 is not have updated medical assessment, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Licensee will submit new medical assessment and provide annually.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
Page: 7 of 14


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: SUPERCARE GUEST HOME
FACILITY NUMBER: 198603358
VISIT DATE: 12/09/2023
NARRATIVE
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Bathrooms 1-2: Water temperature in bathroom was within 105–120 degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet. LPA Ramirez observed chemicals and cleaning solutions, located in under bathroom#1 sink cabinet, to accessible to six (6) out of six (6) residents in care.

Backyard: No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: Last documented fire drill was conducted on 11/12/23 at 2:15 pm

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed five (5) personnel records. Documented proof of required annual initial dementia training required within the first 4 weeks of employment was not observed for four (4) out of the five (5) personnel records reviewed. Staff#3 (S3) did not have documented proof of criminal clearance of criminal exemption. Administrator Certificate was observed for Janice Jabonero with an expiration date of 03/23/2024.

Resident Files: Six (6) resident files were reviewed. LPA did not observe required physician’s report for R6. LPA Ramirez did not observe required annual physician’s report for R2.

Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance during visit. LPA Ramirez observed updated infection control plan.



Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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