<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603544
Report Date: 03/16/2023
Date Signed: 03/20/2023 09:04:23 AM

Document Has Been Signed on 03/20/2023 09:04 AM - 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:LOVE BEYOND WORDS RESIDENTIAL CAREFACILITY NUMBER:
198603544
ADMINISTRATOR:PIPER, TONIEFACILITY TYPE:
735
ADDRESS:14516 TACUBA DRIVETELEPHONE:
(310) 650-0545
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 5DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Tonie Piper TIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon visit LPA met with staff Kenia Turcios and discussed the purpose of the visit. Administrator Tonie Piper arrived shortly after.

LPA started the Care Tools. LPA conducted a tour of the facility along side with Tonie. Facility is a one story family home with three (3) bedrooms, two (2) bathrooms, living room, kitchen, dining area, a den, an attached garage for laundry and storage, and a backyard with shaded area for clients. There are currently five (5) clients who are on assisted living waivers.

Physical Plant: Outdoor and indoor passageways are free of obstruction. Bathrooms were clean and operational with grab bars and non-ski mat, water temperature in compliance. Smoke/carbon monoxide detectors were tested and operational. The last fire drill was conducted on 1/19/23. The fire extinguisher observed. Required postings observed. Sufficient supply of extra linen, towels and personal hygiene supplies observed. Central Air and Heating with temperature comfortable. Washer/Dryer appliances observed and operational. Front and back yard is in good condition, shaded area is provided. Sufficient non-perishable and perishable food items for clients in care, emergency supplied observed. Toxins and sharps locked and inaccessible to clients. BEDROOMS: Bedrooms #1-#3 had required furnishing. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads.
MEDICATION: Medications are stored, locked and inaccessible to clients. LPA reviewed (5) client medications
RECORD REVIEW: Facility Administrator Certificate for Tonie Piper is active. Three(3) Staff Files reviewed. Five (5) client filed reviewed

Care Tool was completed and based on Title 22 Regulations, a Deficiency will be documented on LIC 809D and Civil Penalty issued.

An exit interview was conducted and a copy of today's reports / appeal rights were provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/20/2023 09:04 AM - It Cannot Be Edited


Created By: Jose Villalobos On 03/16/2023 at 01:55 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: LOVE BEYOND WORDS RESIDENTIAL CARE
FACILITY NUMBER: 198603544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Resident #1 and Resident #2 are listed as non-ambulatory based on their physicians report but are in rooms not cleared for non-ambulatory clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
1
2
3
4
Licensee contacted fire department to notify of non-ambulatory clients for the purpose of Fire Watch. Licensee to submit LIC 200 for change in amb/nonamb/ bedridden clearance to licensing by POC Due date and provide LPA with a copy.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2