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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004205
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:46:21 PM

Document Has Been Signed on 03/11/2025 04:46 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TOTAL CARE RESIDENTALFACILITY NUMBER:
306004205
ADMINISTRATOR/
DIRECTOR:		NORLAN MACHADOFACILITY TYPE:
735
ADDRESS:20220 MAPESTELEPHONE:
(562) 229-1999
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Julie Machado, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced Annual Inspection and met with Assistant Administrator Julie Machado who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. Norlan Machado, Staff arrived and assisted LPA with the visit. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (4) Ambulatory Adults ages 18 through 59. The home is vendored through Harbor Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

Infection Control Plan: The facility has an updated Infection Control Plan in place. The staff practice hand washing and using gloves in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies.

Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes kitchen, living room, dining area, four (4) client’s bedrooms, staff bathroom, two (2) client bathroom, laundry room and an attached garage. Bedroom#1 has two beds, two chairs, two drawers, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, one drawer, required furniture and bedding and sufficient closet space and lighting. The client bathroom is clean, sanitary and in a good working condition. Toilets and faucets are in working condition. The hot water temperature tested between 119 and 119.5 degrees F which is within the Title 22 regulation.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TOTAL CARE RESIDENTAL
FACILITY NUMBER: 306004205
VISIT DATE: 03/11/2025
NARRATIVE
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Physical Plant and Environmental Safety: All the kitchen appliances are working properly. All the sharp knives are stored and locked in the kitchen cabinet and all the cleaning supplies are stored and locked under the sink. The hallway light is on during nighttime so clients can have access to the non-private bathrooms. The extra personal hygiene products are stored in the hallway cabinet. The extra linen and towels are stored in the hallway cabinet next to the bathroom. Facility has a telephone service on the premises. The passageway, walkway and backyard are free of obstruction. Carbon monoxide detectors were tested and working properly. Fireplace is closed, secure, and inaccessible to clients. The fire extinguishers were in the kitchen and garage, fully charged and last inspected on 3/28/2024.

Operational Requirement: Facility Administrator is adhering to operational requirements. The facility would support client to participate community activities. The facility has a shaded area with table and chairs for client to utilize the outdoor activity.

Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the updated facility planned emergency procedure training.

Personnel Records/Staff Training: All the staff files are stored in the file cabinets. LPA reviewed five staff files which are over 18 years old with background check cleared and associated with the facility. LPA inspected five (5) staff files and they all have the required documents in files: Personnel Record, Health screening, TB Test result, updated first aid certificate Employee Rights, and required training hours. The facility administrator is Mary Machado and his administrator certificate expired date on 12/20/24 but pending renewal. The administrator does not have the required and updated HIV and TB training certificate in file. Based on record review, Staff #1 (S1’s) Health Screening and TB screening document was not in file. Based on record review, Admin, Assistant Admin, Staff #1 (S1) to Staff #3 (S3) did not have Valid First Aid Training in file.

Client's Rights: The facility does not have any client with postural support at the present time. The facility would provide internet service with internet access device for client to communicate with their families or day program or their medical professional.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TOTAL CARE RESIDENTAL
FACILITY NUMBER: 306004205
VISIT DATE: 03/11/2025
NARRATIVE
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Food Service: The facility has ample supply for two days perishable and seven days non-perishable food supply in the facility. All the food in the facility are stored properly. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are clients that have restricted health conditions.

Client Records and Incident Reports: The client's files are stored in the file cabinet near the living room. LPA reviewed Client files for Client #1 (C1) through Client #4 (C4). Client files are maintained at the facility and have the following documents in their files - Face sheet, Physician's Report (including T.B and Ambulatory Status), Immunization records, Individual Program Plan (IPP), Functional Capabilities Assessment, Client Centrally Stored Medication Destruction Record, Safeguards for Cash Resources, Safeguards for Property/Valuables, and Clients Personal Rights.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items. Facility staff provide transportation to medical and dental appointments.

Incidental Medical Services: The facility does not have any client with restricted health condition plan and they are not retaining any client with prohibited health condition.

Disaster Preparedness: The facility did not have an updated emergency disaster plan (LIC610D) in file. The last fire/disaster drill was conducted on 3/3/2025.

Emergency Intervention: The facility does not use any restraints on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to Assistant Administrator Julie Machado.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/11/2025 04:46 PM - It Cannot Be Edited


Created By: Daniel Konishi On 03/11/2025 at 04:20 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: TOTAL CARE RESIDENTAL
FACILITY NUMBER: 306004205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the administrator does not have the required and updated HIV and TB training certificate in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator will send the updated HIV and TB training certificate to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review,Staff #1 (S1’s) Health Screening was not in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator will send the copy of Staff #1 (S1's) Health Screening to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/11/2025 04:46 PM - It Cannot Be Edited


Created By: Daniel Konishi On 03/11/2025 at 04:20 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: TOTAL CARE RESIDENTAL
FACILITY NUMBER: 306004205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, Staff #1 (S1’s) TB screening document was not in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator will send Staff #1 (S1's) TB screening document to the LPA by the POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Admin, Assistant Admin, Staff #1 (S1) to Staff #3 (S3) did not have Valid First Aid Training in file. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator will send a copy of Admin, Staff #1 (S1) to Staff #4 (S4's) valid First Aid training to the LPA by the 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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/11/2025 04:46 PM - It Cannot Be Edited


Created By: Daniel Konishi On 03/11/2025 at 04:20 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: TOTAL CARE RESIDENTAL
FACILITY NUMBER: 306004205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not have a updated Emergency and Disaster plan in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator will send the updated Emergency and Disaster plan to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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