306001749-3-30-2022-22-AS-PVEZ-CCZTR2-20220330145650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001749
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:56:55 PM

Document Has Been Signed on 03/30/2022 02:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ARVILINH HOME CARE		FACILITY NUMBER:	306001749
ADMINISTRATOR:	ARVIN BUMANGLAG		FACILITY TYPE:	740
ADDRESS:	9351 MELBA DRIVE		TELEPHONE:	(714) 643-9077
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Arvin Bumanglag - Administrator		TIME COMPLETED:	03:15 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) Patricia Velazquez conducted an unannounced visit to Arvilinh Home Care. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Maria Balonghit. Caregiver Irene Kendig was also present. Administrator (AD) Arvin Bumanglag was also present. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 4 residents. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on December 1, 2021. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised AD to obtain the Complaint poster in the correct size of 20" x 26" and to prominently display it in the entry area. AD did provide a Complaint poster in the correct size but it was torn and not in good condition. At 1:38 PM LPA Velazquez conducted a tour of the physical plant along with AD Bamanglag. The 1 story home consists of 6 resident bedrooms and 3 bathrooms. The facility also has a living room, dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails in the resident bedrooms. One resident had 3/4 bed rails but per AD was not receiving hospice services. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 127.2 degrees Fahrenheit in the first bathroom, at 127.7 degrees Fahrenheit in the second bathroom, and at 124.3 degrees Fahrenheit in the third bathroom which AD verified.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
	VISIT DATE: 03/30/2022

NARRATIVE

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LPA Velazquez inspected the kitchen along with AD Bumanglag. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. There were no auditory alarms present in the facility and AD proceeded to begin installing and completed the installation during LPA's visit. First Aid kit was checked and found to be in order. The facility did not have a First Aid manual and LPA Velazquez advised AD Bamanglag to obtain an updated First Aid manual.

LPA Velazquez along with AD Bamanglag toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and LPA observed the 2 exit gates were not in operating condition and AD Bamanglag initiating the repair of the exit gates. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AD Bamanglag to ensure a written physician's order indicating the need for the bed rails and other postural supports is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with AD Bamanglag.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Arvin Bamanglag and a copy of this report along with the appeal rights, and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2022 02:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degee F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 bathrooms where the hot water measured over 120 degree F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water is maintained pursuant to regulation at all times and submit written proof to LPA by POC due dates.

Type A

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
	Deficient Practice Statement
1 2 3 4	Based on (observation and interview, the licensee did not comply with the section cited above in 4 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2022
	Plan of Correction
1 2 3 4	Licensee to ensure there is written physician order for the postural supports in each resident's file and submit written proof 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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