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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001749
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:42:51 PM


Document Has Been Signed on 04/11/2024 02:42 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 CAREFACILITY NUMBER:
306001749
ADMINISTRATOR:ARVIN BUMANGLAGFACILITY TYPE:
740
ADDRESS:9351 MELBA DRIVETELEPHONE:
(714) 643-9077
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Arvin BumanglagTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of conducting a Plan of Correction (POC) inspection. LPA met with Administrator (AD) Arvin Bumanglag and discussed the purpose of the inspection.

LPA is following up on deficiencies cited on 3/21/24, during required/annual inspection. Deficiency 87465(h)(5) was cited due to resident medication not being kept in its original containers and being pre-prepared a week in advanced in a weekly medication organizer. During today's visit, LPA confirmed all resident medication is being kept in its original containers and is no longer being pre-prepared a week in advance. AD stated in-service for staff training will be conducted 4/13/24. AD will provide LPA with proof via email once completed.

87457(c)(1) was also cited due to one out of four resident files not containing an appraisal which includes an evaluation of the resident's functional capabilities, mental condition and an evaluation of social factors. AD stated resident appraisal was completed and provided LPA with completed resident appraisal dated 3/31/24.

One of two deficiencies previously cited will be cleared.

Based on today’s observations no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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