198603521-1-16-2024-28-AS-KRAZ-CZK7HE-20240116204033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603521
Report Date: 01/16/2024
Date Signed: 01/16/2024 08:42:07 PM

Document Has Been Signed on 01/16/2024 08:42 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:	A PEACEFUL HOME OF COVINA		FACILITY NUMBER:	198603521
ADMINISTRATOR:	BUGASTO, MYRNA G.		FACILITY TYPE:	740
ADDRESS:	16025 E BRIDGER ST.		TELEPHONE:	(626) 244-9999
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 5	DATE:	01/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:09 AM
MET WITH:			TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 01/16/2024.
LPA was met by Administrator Elizah Arganosa and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which five (5) may be non-ambulatory and has a hospice waiver approved for six (6).

LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of five (5) resident bedrooms, two (2) bathrooms (one shared and one private), 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 knives, sharps and disinfectants to be inaccessible to residents.

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 1-5: LPA Ramirez inspected five (5) 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. Fire clearance is approved for (5) non-ambulatory residents in rooms #1, 2, 4, and 5. Bedroom #3 is approved for (1) bedridden.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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: A PEACEFUL HOME OF COVINA	FACILITY NUMBER: 198603521
	VISIT DATE: 01/16/2024

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Bathrooms 1-2: Water temperature in bathrooms was within 105–120-degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet.

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

Emergency Drills: Last two (2) documented fire drills were conducted on 01/02/204 at 9:30 am & 12/07/2023 at 2pm.

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 training was present, however, the training did not document dementia hours. LPA Ramirez will issue Technical Violation. Administrator’s Certificate for Elizah Faye Arganosa with an expiration of 10/21/2024.

Resident Records: Five (5) resident records were reviewed. LPA Ramirez observed five (5) resident medications and Medication Administration Records (MAR).

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

Technical violations are being cited. A copy of this report, LIC 9120 and appeals rights was provided via email.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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