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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603627
Report Date: 02/22/2024
Date Signed: 02/27/2024 10:54:30 AM


Document Has Been Signed on 02/27/2024 10:54 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:LOVING ARMS RESIDENTIAL CARE FOR SENIOR IFACILITY NUMBER:
198603627
ADMINISTRATOR:MACANDILI, EDJESKAFACILITY TYPE:
740
ADDRESS:11503 THOMAS PLACETELEPHONE:
(562) 864-6308
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Joan AmorotoTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Lourdes Bisnar and explained the purpose for todays visit. The facility phone number is 562 404 8387.

The facility consist of four resident bedrooms, two bathrooms(one in bedroom #1), a living room, dining room, kitchen, attached garage/staff room, and a patio located in the back yard.

The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen. The water temperature was tested and measured between 105 and 120 degrees F.

Administrators certificate for Edjeska Mian N Macandili #6027336740, expired on 07/28/2023. The licensee is waiting on her new certificate to arrive and provided proof.

Continued on LIC 809C.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2024 10:54 AM - 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: LOVING ARMS RESIDENTIAL CARE FOR SENIOR I
FACILITY NUMBER: 198603627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
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The licensee shall have the item repaired or replaced and send the receipt of repair or replacement to LPA Wesley by POC 03/23/24.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
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)
Page: 2 of 4


Document Has Been Signed on 02/27/2024 10:54 AM - 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: LOVING ARMS RESIDENTIAL CARE FOR SENIOR I
FACILITY NUMBER: 198603627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(3)
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's observation, the licensee did not comply with the section cited above by having a lock on the refrigerator(see pictures), and a small video camera in all of the residents room(see pictures), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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The licensee/administrator shall read section 87468.1(Personal Rights) and provide a written statement that they will not violate the residents personal rights. Send proof that you read the section, and the statement to CCLD/Attn Nicol Wesley by POC date 03/01/24.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
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)
Page: 3 of 4


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: LOVING ARMS RESIDENTIAL CARE FOR SENIOR I
FACILITY NUMBER: 198603627
VISIT DATE: 02/22/2024
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Staff person Joan Amoroto was also informed that they can not have an employee working in all the 3 licensed residents at once, they may work 1 staff per residence. The backyards connect and they enter the property from the backyard. 11503, 11507, 11511 are all licensed facility's on the same street.


The following citations were cited per the California Code of regulations, Title 22 on the LIC 809D's

Appeal rights given

Exit interview conducted
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
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)
Page: 4 of 4