198603544-2-21-2025-28-AS-EZAA-DE4W3L-20250221155606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603544
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:56:34 PM

Document Has Been Signed on 02/21/2025 03:56 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 CARE		FACILITY NUMBER:	198603544
ADMINISTRATOR/ DIRECTOR:	PIPER, TONIE		FACILITY TYPE:	735
ADDRESS:	14516 TACUBA DRIVE		TELEPHONE:	(310) 650-0545
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 6		CENSUS: 5	DATE:	02/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	Bree Broach - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Bree Broach, Administrator for the facility, and explained the purpose of the visit. There are four (4) ambulatory and one (1) non-ambulatory clients residing in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices were observed. LPA observed that the facility has a completed infection control plan.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of three (3) client bedrooms, a kitchen, a dining room, a living room, a dining room, an attached garage that contains the facility’s laundry area, and two client restrooms of which the men’s restroom had a hot water temperature reading of 108.4 Degrees Fahrenheit, and the women’s restroom had a hot water temperature of 127.7 Degrees Fahrenheit, which is above the required 105 – 120 Degree Fahrenheit range. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area was available for clients in the backyard of the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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 02/21/2025 03:56 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 02/21/2025 at 03:36 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: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 5 clients, as the women's restroom has a hot water temperature of 127.7 Degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2025
	Plan of Correction
1 2 3 4	Administrator is to ensure the hot water temperature for all clients remains within 105 - 120 Degrees Fahrenheit at all times. Administrator is to keep a water temperature log of the women's restroom and email the log to the LPA by the POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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: LOVE BEYOND WORDS RESIDENTIAL CARE	FACILITY NUMBER: 198603544
	VISIT DATE: 02/21/2025

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system and carbon monoxide detectors are operational. The facility has two (2) fully charged fire extinguishers that are kept throughout the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.

Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) ambulatory clients between the ages of 18 – 59.

· The facility is currently working towards finding a temporary placement for the non-ambulatory client, and have been working on updating the fire clearance to increase their non-ambulatory capacity.
· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of nine (9) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires in 2026.

· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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: LOVE BEYOND WORDS RESIDENTIAL CARE	FACILITY NUMBER: 198603544
	VISIT DATE: 02/21/2025

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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Five (5) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.

· The last documented disaster drill was documented on 1/5/2025.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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