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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004032
Report Date: 03/16/2022
Date Signed: 03/21/2022 10:35:30 PM

Document Has Been Signed on 03/21/2022 10:35 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:CERRITOS HOME CAREFACILITY NUMBER:
306004032
ADMINISTRATOR:EDITH PARRENOFACILITY TYPE:
735
ADDRESS:11541 BINGHAM STREETTELEPHONE:
(562) 860-3057
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Judith Delos Reyes TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Caregiver Judith Delos Reyes and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures and observed food supply, and reviewed clients files. Facility has submitted a mitigation plan and was approved 03/10/21.

The facility is a single story house and located in a residential neighborhood. The facility consists of living room, kitchen, dining area, four clients bedrooms, two bathrooms and an attached garage. LPA toured the client's bedroom. Each room has one bed, one dresser, one chair, required linen, sufficient lighting and closet space. The bathrooms are clean and operational. The hot water temperature was measured between 125 and 127 degrees F which is out of the range of Title 22 regulation. The food supply in the refrigerator and garage which included two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and has a shaded with table and chairs for clients to utilize. The exit and passage way are free of obstruction. The sharp utensils are locked in the kitchen cabinet and the cleaning supplies are located in the garage and inaccessible to clients. The medication are centrally stored and locked in the kitchen cabinet and inaccessible to clients. The smoke detectors and carbon monoxide detectors are located in each client bedroom and common area and they are operating well.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected every day or as needed or every time client used, the bathrooms have sufficient soap, paper towels, and signs and PPE supplies are stored for more than 30 days.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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Document Has Been Signed on 03/21/2022 10:35 PM - It Cannot Be Edited


Created By: Christine Wong On 03/16/2022 at 02:10 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: CERRITOS HOME CARE

FACILITY NUMBER: 306004032

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture Fixtures, Equipment and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the hot water in both bathrooms was measured at 125 and 127 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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The administrator will fix the hot water immeidiately within the Title 22 regulation and send the seven days hot water log to LPA by POC due dae (3/23/22)
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


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: CERRITOS HOME CARE
FACILITY NUMBER: 306004032
VISIT DATE: 03/16/2022
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The following deficiency is cited under the California Code of Regulations Title 22 Division 6 Chapters 1 and documented on the attached LIC 809D

An exit interview was conducted. This report was reviewed with Judith Delos Reyes (caregiver) and a copy of this report and appeal rights provided to Mrs. Reyes.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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