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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 12/13/2022
Date Signed: 12/13/2022 02:37:09 PM


Document Has Been Signed on 12/13/2022 02:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HENRIETTA'S HOMEFACILITY NUMBER:
198603585
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 703-4958
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 4DATE:
12/13/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Belen Taico, StaffTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Post Licensing visit. LPA explained the purpose of the visit to staff Belen Taico. Administrator Robin Aquino and Director of Assisted Living Stephany Perez were explained the purpose of the visit telephonically. The facility is a single story home located in a residential neighborhood licensed for six (6) non-ambulatory residents; of which one (1) may be bedridden. The facility has a hospice waiver for four (4) residents. The last emergency drill was conducted on 10/20/2022. Administrator certificate expires 11/14/2023.

OBSERVATIONS:
  • The facility does not have a copy of the correct license. The previous licensee's license was posted and filed in a facility binder. Director of Assisted Living stated the corporate office has the license. Ms. Perez emailed staff a copy. It was printed and posted during the visit.
  • There are two (2) residents receiving hospice services.
  • Visitors are screened at the facility entrance. COVID-19 Infection Control Practices and signs were observed in the main entrance and bathrooms. Adequate supply of Personal Protective Equipment (PPE's) was observed.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors were tested and operational.
  • A posted Emergency Disaster Plan was observed.
  • Four (4) centrally stored client medication records were reviewed.
  • Staff were observed wearing mask. Residents were not observed wearing masks due to cognitive impairment.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Sharps/knives and toxins were locked.
  • Staff have criminal background clearance.
  • Resident files were reviewed. Three (3) out of four (4) resident files did not have new Admission Agreements issued by this licensee. The files had Admission Agreement contracts of previous licensee.
Per California Code of Regulations, Title 22, deficiencies were observed. See LIC 809D.
Exit interview was conducted with staff Belen Taico. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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 3


Document Has Been Signed on 12/13/2022 02:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87109(a)
Transferability of License
(a) The license shall not be transferable.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the previous licensee's facility license was posted and filed at the facility; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
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4
Director of Assisted Living Operations emailed staff a copy of the correct licensee's license. Staff printed the copy and posted it at the facility. CLEARED during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/13/2022 02:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: HENRIETTA'S HOME
FACILITY NUMBER: 198603585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(e)
Admission Agreements
The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 3 out of 4 residents (R1-R3) did not have current admission agreements issued by the new licensee; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2023
Plan of Correction
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Administration staff agreed to submit proof that residents (R1-R3) were issued updated Admission Agreements from new licensee.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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