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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003747
Report Date: 02/18/2023
Date Signed: 02/18/2023 05:06:24 PM

Document Has Been Signed on 02/18/2023 05:06 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MAPLE HOMEFACILITY NUMBER:
306003747
ADMINISTRATOR:ROMMEL P. GONZALESFACILITY TYPE:
735
ADDRESS:9435 MAPLE STREETTELEPHONE:
(562) 867-4235
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
02/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:DSP Kristen RodriguezTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an annual inspection with the focus on the Infection Control Practice domain. LPA Pena met with DSP Kristen Rodriguez and discussed the purpose of the visit. The Administrator was called on the phone but is currently outside of the country. The facility does not have any designated Administrator. The facility is approved for four (4) Developmentally Disabled Adults, ages 18-59, ambulatory only. Current census is (4) ambulatory clients. The home is vendorized by Harbor Regional Center. LPA observed that one of the staff present and working in the facility, Emma Lei Jamero, was not associated nor have documents for criminal background clearance. Staff Emma left the facility as soon as LPA confirmed that she was not associated and could not provide documentation of criminal background clearance. Shortly after, another DSP, Rosita Eramela arrived in the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications and observed food supplies. This facility is a single-story home located in a residential area. There are 4 client bedrooms, 1 staff bedroom, 2 full bathrooms, living room, dining room, kitchen, laundry space, backyard and a detached garage.

LPA along with DSP Kristen Rodriguez toured the facility and observed/inspected the following:
  • The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer.
  • Staff did not screen LPA and did not check temperature upon arrival.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • Both staff on duty were not wearing face coverings/mask, but wore the mask after being prompted by LPA.
  • Facility has 30 days of PPE supplies.
  • There are 4 bedrooms designated for clients and 1 for staff. Client rooms are equipped with the required furnishings.
  • Kitchen knives/sharps and medications are locked in a cabinet.
  • Cleaning solutions are stored and locked under the kitchen sink.
  • Sufficient food supply of 2-day perishable and 7-day nonperishable were observed.
  • Laundry room is clean, located next to the kitchen and has cleaning supplies inaccessible to clients.
  • The fire extinguisher has been purchased recently.
  • Hot water temperature was measured within the required range of 105-120 degree Fahrenheit.
  • The backyard has a shaded area with tables and chairs for clients use.
  • The detached garage contained some food supplies, refrigerator, incontinence supplies and other basic supplies. LPA observed broken tiles on the floor and partly ripped ceiling.
  • There are no obstructions to the passageways or bodies of water at the facility.
  • Medications were reviewed for all 4 clients and did not observe any discrepancies.
  • Staff and client files were not reviewed during today's visit.


Deficiencies were cited, exit interview conducted, and copy of the report and appeals rights were provided to the DSP, Kristen Rodriguez.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2023
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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Document Has Been Signed on 02/18/2023 05:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/18/2023 at 03:36 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: MAPLE HOME
FACILITY NUMBER: 306003747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in that LPA observed that the detached garage has broken tiles on the floor and ripped ceiling which posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/03/2023
Plan of Correction
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The Administrator will submit photos of the repaired ceiling and tiles on the floor along with receipts or service order to LPA on or before the 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2023 05:06 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/18/2023 at 03:47 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: MAPLE HOME
FACILITY NUMBER: 306003747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(b)(f)
85064 Adminstrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator.
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the Administrator did not submit LIC308/Designation of facility responsibility to another qualified Administrator before he left internationally which posed an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/20/2023
Plan of Correction
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The Administrator will submit signed letter that he read, reviewed and understood Title 22 Regs. 85064 and submit proof that co-Administrator, Marion Gonzales has submitted renewal/recertification to CCLD. Both requirements must be submitted to LPA by POC due date.
Type A
Section Cited
CCR
80019(a)(2)(C)(D)
80019 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals ..........presence in the facility, based upon the results of such review.(2) Section 1522(b) of the Health and Safety Code provides in part: (C) Any person who provides client assistance..(D) Any staff person, volunteer, or employee who has contact with the clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview,record review, the Administrator did not comply with the section cited above in which one staff, Emma Lei Jamero who was working and present was not associated nor proof or documents for criminal clearance which posed a potential health, safety or personal rights risk to clients in care.

POC Due Date: 02/20/2023
Plan of Correction
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LPA advised Administrator that S1 cannot be present and/or working at the facility until criminal record clearance has been received and S1 has been associated to the facility. Administrator to submit Criminal Record Clearance 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2023


LIC809 (FAS) - (06/04)
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