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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603602
Report Date: 12/09/2023
Date Signed: 12/09/2023 04:15:06 PM

Document Has Been Signed on 12/09/2023 04:15 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:B.M.W. LOVED ONES ARF, INC.FACILITY NUMBER:
198603602
ADMINISTRATOR:HOWARD, BETTYFACILITY TYPE:
735
ADDRESS:15217 BARNWALL STTELEPHONE:
(310) 569-1721
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
12/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Keeonna Sorrels - CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Keeonna Sorrels (Caregiver) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by Eastern Los Angeles Regional Center.

The facility is a single-story home located in a residential area in La Mirada, Ca. A tour of the facility includes: living room, dining room, kitchen, laundry closet, cleaning supply closet, linen closet, 3 bathrooms, 4 bedrooms, attached garage, front yard, back yard and a locked tool shed.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.


Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature in all client bathrooms were tested and outside the required range of 105-120 degrees F, measuring at 131.2, 131.8, and 132.9 (details will be cited on the 809-D). All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients, however, during todays visit cleaning supply closet within hallway was observed to be unlocked (details will be cited on 809-D). Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 7/10/23, these drills must be conducted every 3 months (quarterly), details will be cited on the 809-D.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2023
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 5
Document Has Been Signed on 12/09/2023 04:15 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/09/2023 at 03:31 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: B.M.W. LOVED ONES ARF, INC.
FACILITY NUMBER: 198603602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as during facility tour LPA observed cleaning supply closet in hallway to be unclocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2023
Plan of Correction
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**Staff immediatly locked cleaning supply closet during visit**
Licensee to conduct a training for all staff in proper storage of disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients to ensure clients are free from potential harm. A copy of the training materials and training log to be submitted to LPA via email by 12/27/23.
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
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Based on observation, the licensee did not comply with the section cited above as during facility tour LPA measured water temperature in each bathroom and readings were 131.2, 131.8, and 132.9 degrees F wihch are above the required range of 105-120 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2023
Plan of Correction
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**Staff currently on site is not sure how to lower the water heater temperature, however, next staff scheduled for 4pm will lower water temperature upon arrival**
Licensee to email LPA once water temperature is lowered, temperature must be lowered by tomorrow 12/10/23.
Licensee to create a water temperature log (date begining 12/10 / ending 12/14) and test water temperature for the next 5 days, each reading must be within the required range of 105-120 degrees F and temperatrue must be tested 3 times a day (morning,day,evening). The water temperature log must be emailed to LPA by 12/15/2023.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/09/2023 04:15 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/09/2023 at 03:31 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: B.M.W. LOVED ONES ARF, INC.
FACILITY NUMBER: 198603602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

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 as the last fire/earthquake drill was conducted on 7/10/23, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licensee to conduct a fire drill and email a copy of report with attendee names and date drill was conducted to LPA via email by POC due date. Licensee to conduct quarterly fire and earthquake drills and have documentaion of drills in facility file moving forward.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 as 1 out of 4 staff files did not have the required first aid certificate, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licensee to submit proof of staff Kimberly Fuller valid First Aid Certificate via email to LPA by POC due date.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/09/2023 04:15 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/09/2023 at 03:31 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: B.M.W. LOVED ONES ARF, INC.
FACILITY NUMBER: 198603602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

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 1 out of 4 client files were missing current physician report that states ambulaory status and tb result, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Licensee to provide LPA with client #3 (W.Tettey) physician report and ensure that moving forward all client files hold all required documents per title 22 regulations. Proof of Physician Report must be submitted to LPA via email 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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: B.M.W. LOVED ONES ARF, INC.
FACILITY NUMBER: 198603602
VISIT DATE: 12/09/2023
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a locked medication closet. LPA reviewed 4 staff files during today’s visit. 1 out of 4 files were missing their First Aid Certificate all others contained the following: criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Betty Howard certificate expires on 3/14/2024.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides internet and telephone landline for the clients.
Client Records-Incident Reports: Client files are maintained in the locked medication closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report (1 out of 4 client files are missing their physicians report), Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 3 clients medications and there were no issues observed. (1 client is currently not on any medication)
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills (facility is past due for their emergency drill by 2 months – details cited on the 809D)
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques, however, all staff maintain a CPI certificate incase a manual restraint is needed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D).

Exit interview was held and a copy of the report was provided to Keeonna Sorrels.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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