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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603544
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:39:25 PM

Document Has Been Signed on 02/22/2024 02:39 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: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:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Bree Broach, House LeadTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 2/22/24. LPA met with House Lead, Bree Broach, and explained the purpose of the visit. Administrator, Tonie Piper, arrived shortly thereafter. The facility is licensed to serve 6 ambulatory adults, ages 18 through 59.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tool during the inspection today. The following were observed:
Infection Control: The staff are performing appropriate hand hygiene and wearing gloves when necessary to assist clients. Staff are continuing to clean and disinfect each shift.
Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 3 client bedrooms, 2 bathrooms, living room, dining room, a den, kitchen, and attached garage. The fireplace is secured with a fence. Each client bedroom has the required furniture. There are no items obstructing the hallways or walkways. Facility has smoke and carbon monoxide combo detectors throughout the facility. Knives and cleaning solutions are locked in the kitchen area. The facility measures and documents the water temperature every shift to ensure the hot water is within the required range of 105-120 degrees F.
Operational Requirements: There are currently 5 clients residing at the home under the assisted living waiver program. Proper care and supervision is being provided to the clients. During the visit, LPA observed a client who utilizes a wheelchair.
Staffing: There is sufficient staffing at the facility. Per the administrator, there are 2 awake staff for the overnight shift monitoring the clients.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 4 Staff files. Administrator (Tonie Piper) has submitted documents to renew the administrator's certificate. LPA verified the documents have been received and is pending approval by the Administrator Certification Bureau. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: LOVE BEYOND WORDS RESIDENTIAL CARE
FACILITY NUMBER: 198603544
VISIT DATE: 02/22/2024
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Clients Rights - Information: Client rights are posted at the facility. Facility provides internet for client to use.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed (5) client files and they have the required documentation including current Individual Program Plan. There is one client with a restricted health condition and proper documentation is observed in the file. Client #5 physician's report states that the client is non-ambulatory.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Client are provided with at least 3 meals per day.
Health-Related Services: Medications are centrally stored and locked in the kitchen area. The staff documents medications given daily. LPA reviewed medications for 5 clients and they are being administered as prescribed by the physician.
Incidental Medical & Dental: There is one client receiving home health services. There are no clients with prohibited health conditions.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures annually and know where the utility shutoff valves are located. LPA provided a technical advisory for the emergency disaster drills that shall be conducted at least quarterly.
Emergency Intervention: Staff do not utilize any manual restraints at the facility.

A deficiency and immediate civil penalty of $500 are issued today. An exit interview was held with the administrator. A copy of this report along with appeal rights were given.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/22/2024 02:39 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 02/22/2024 at 01:56 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: 02/22/2024

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 and record review, the licensee did not comply with the section cited above in which Client #5 is identified as non-ambulatory which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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The licensee will contact fire department to notify of the non-ambulatory client for the purpose of Fire Watch. Licensee will submit the LIC 200 form for the change in ambulatory to nonambulatory status to 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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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