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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004063
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:04:22 PM

Document Has Been Signed on 11/21/2022 03:04 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:DALE B&C HOMEFACILITY NUMBER:
306004063
ADMINISTRATOR:SOPHEAP THONGFACILITY TYPE:
735
ADDRESS:8562 DAVMOR AVENUETELEPHONE:
(714) 537-8718
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 6DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sam-Ylerma Lerma
Sopheap Thong		TIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by Staff Sam-Y Lerma and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and Staff Lerma conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with four bedrooms, and two bathrooms, with one bedroom being occupied by staff. Administrator (AD) Sopheap Thong arrived during the inspection at 2:19 p.m. Clients were observed resting in their respective rooms and in the living room area of the facility. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were not met; a Deficiency was issued on this date. LPA observed the facility has a 30-day supply of PPE on hand.

LPA reviewed and confirmed facility policies and practices regarding resident screening; a Technical Advisory was given on this date, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control; a Technical Advisory and Deficiency was issued on this date, PPE, and staffing.

Based on the observations made during today’s inspection, two 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 appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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 11/21/2022 03:04 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 11/21/2022 at 02:13 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(h)(1)
Health-Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: (1) The name, address and telephone number of each client's physician and dentist, and other medical and mental health providers, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four client files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2022
Plan of Correction
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Adminsitrator (AD) Sopheap Thong stated they will update forms and email LPA Claudia Gutierrez copies of completed and up to date information by POC due date.
Type B
Section Cited
CCR
80087(a)(1)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employess, and visitors. (1)The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of three bathrooms, and in the kitchen, LPA observed insects flying around and obtained pictures of at least two insects, this poses a potential health and safety risk to persons in care.
POC Due Date: 12/21/2022
Plan of Correction
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Administrator (AD) Sopheap Thong stated they will create a plan of action for meeting the requirement which includes how to keep the facility free of flies and other insects and will be submitted by POC due date to LPA via email.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


LIC809 (FAS) - (06/04)
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