198603661-12-22-2023-28-AS-NGAA-CYRRZV-20231222122835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603661
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:28:43 PM

Document Has Been Signed on 12/22/2023 12:28 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:	EXCELLENCE BOARD AND CARE LLC		FACILITY NUMBER:	198603661
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	12551 DOWNEY AVE.		TELEPHONE:	(818) 799-7218
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY:	6	CENSUS: 0	DATE:	12/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rey John Bertulfo, Licensee		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Galarza made an Announced visit and met with Licensee Rey John Bertulfo and Administrator Alma Espinal to conduct a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. A Dementia waiver and a hospice waiver for six (6) is in place. The requested capacity is for two (2) non-ambulatory and four (4) bedridden in rooms #5, #6, #7, and #8. Structure: Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage.Front and back yards are landscaped with grass. Bedroom Clients: Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lighting. Bathrooms: Total of 10 bathrooms, one (1) half bath and 9 full bathrooms with working toilets, wash basins, and walk-in showers, with the exception of room #2, which has a large bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Seven (7) fully charged fire extinguishers were observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. *Narrative continues next page.**

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

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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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: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
	VISIT DATE: 12/22/2023

NARRATIVE

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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was not within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the dining room. Pools/Jacuzzi/Body of Water & Pets: The backyard has one (1) inoperable (covered) water fountain in the backyard, and one (1) jacuzzi bathtub in room #2, designated as a staff room. Fire Clearance: Fire clearance was approved on 9/12/23 for two (2) non-ambulatory residents and four (4) bedridden residents. The facility has fire sprinklers. Per Fire Marshall the facility was required to install three (3) fire doors in the north side facility wing, which were tested and observed operational. Component III: Component III was completed.

The following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by 1/19/2024. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. The exit door in the north side yard has a lock that requires a key and the two side gates have lock
mechanism that need to be removed for fire safety.

2. A total of ten (10) windows were observed without screens. Install screens in a windows.

3. Three (3) sliding doors did not have screens. Install sliding door window screens.

4. The storage structure in the rear of the property has personal belongings, discarded furniture, and

gardening equipment. Gardening tools and grass weed killer were observed unlocked in the backyard/
patio area.
5. Outdoor surveillance cameras were observed. Applicant stated they are inoperable. Applicant will remove
them or install new cameras.
6. None of the exit doors and windows have auditory alarms; only sliding doors have them. Install auditory
alarms in all exit door and windows.

An exit interview was conducted and a copy of this report has been furnished to Rey John Bertulfo. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC809 (FAS) - (06/04)

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