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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603653
Report Date: 07/01/2024
Date Signed: 07/02/2024 07:58:37 AM

Document Has Been Signed on 07/02/2024 07:58 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:JOYCE CARING HOMEFACILITY NUMBER:
198603653
ADMINISTRATOR/
DIRECTOR:		BUMANLAG, MYLENEFACILITY TYPE:
735
ADDRESS:13975 LIGHT ST.TELEPHONE:
(562) 693-4073
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Mylene BumanlagTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit to the facility for the purpose of an annual inspection. LPA met with Licensee/Administrator, Mylene Bumanlag, and Licensee, Jennifer Kim.

Structure: Facility is a four (4) bedroom, three (3) full bathrooms, single story house, with a detached garage. Detached garage has been converted to be used as office space. There is a kitchen, dining area, laundry room, and 2 living room areas. Front and backyard landscape are in good condition and free of obstruction or debris. Rear patio is covered and provides shading. Patio furniture, which consists of a table and (5) chairs. Signal System: No signal system in facility. Bedroom Residents: The three (3) client bedrooms each consists of (2) two twin beds with proper bedding, including mattress pads, a dresser, night stand, proper lighting in addition to a lamp, and a chair. Bedrooms contain ample closet space. Bedroom Staff: There is (1) one staff bedroom to be used by live in staff. Bathrooms: (3) full bathrooms are available for resident use. Water temperature measured between 108 F degrees - 114.6 degrees F in all water faucets tested. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, a pillowcase, a mattress pad, a fitted sheet, a blanket and a bedspread. Adequate supply of linen is stored in hallway closets. Emergency Phone Numbers, Personal Rights, Visiting Policy, Exit Plan, & Menu: Emergency Disaster Plan, Personal Rights, Visiting policy, emergency numbers, and menu are posted and readily available for review in dining room area. Facility has a land line telephone located in the living room dining area. One (1) fire extinguisher is located in the dining area and is fully charged. Activity Supplies: sufficient activity supplies were observed. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen cabinet drawer. Dishwasher in kitchen is properly installed and functioning. LPA observed a sufficient amount of perishable and non-perishable food supply on today's visit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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 07/02/2024 07:58 AM - It Cannot Be Edited


Created By: Angelica Rea On 07/01/2024 at 01:35 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: JOYCE CARING HOME
FACILITY NUMBER: 198603653

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

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 1 out of 6 resident files which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that resident #1 did not have a needs and services plan or a medical assessment in his file.
POC Due Date: 07/15/2024
Plan of Correction
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Administrator wlll send resident #1's medical assessment 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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOYCE CARING HOME
FACILITY NUMBER: 198603653
VISIT DATE: 07/01/2024
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Smoke Detectors: There are six (7) smoke detectors throughout the facility, and two (2) battery operated carbon monoxide detector located in the hallway. All were tested and appear to be operating properly. Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. The washer/dryer is located in the laundry area. There is one (2) refrigerators in the home. The home is equipped with three (3) wall air conditioning units: one (1) in the living room and the others in bedrooms #1 & 2. There is central heating. Toxins: Cleaning supplies, and toxins are stored in a locked cabinet in the laundry area. Water Temperature: Water was tested in kitchen and 3 bathrooms. Water temperature measured between 108 degrees F and 114.6 degrees F in all faucets measured. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in locked kitchen cabinet. A first-aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked kitchen cabinet. Client & Staff Files: Designated area for files will be located in locked cabinet in the dining area.

Deficiency cited on 809-D. Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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