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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603706
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:13:18 AM

Document Has Been Signed on 06/21/2022 11:13 AM - 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:MPS HOMEFACILITY NUMBER:
197603706
ADMINISTRATOR:RICARDO BANOSFACILITY TYPE:
740
ADDRESS:5313 FIDLER AVETELEPHONE:
(562) 920-6960
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 4CENSUS: DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Flormine Resurreccion - LicenseeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Licensee Flormine Resurreccion and explained the reason for the visit. The facility is licensed to serve four (4) non-ambulatory, developmentally disabled elderly residents ages 60 and above. Facility is approved for hospice waiver for two residents. Facility currently has 3 non-ambulatory and 1 ambulatory resident. The facility is located in a residential area. A tour of the single-story facility included: living room, kitchen, dining area, 4 resident bedrooms, family room, 2 bathrooms, front yard, backyard and attached garage.

LPA and Flormine Resurreccion toured the facility and the following was observed: the front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 106.9 degrees F and 106.5 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen in each resident bedroom’s closet and clean towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is one carbon monoxide in the hallway and is properly operating. There is a fire extinguisher in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps, cleaning supplies and toxins are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept locked in a hallway cabinet.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MPS HOME
FACILITY NUMBER: 197603706
VISIT DATE: 06/21/2022
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The facility has a video camera surveillance system in all common areas and hallway. All residents signed the video camera surveillance system plan of operation and there was signs posted throughout the facility indicating video camera in use.

Residents medication are centrally stored in a locked cabinet in the living room. Residents and staff files are centrally stored in the medication cabinet. LPA reviewed medication for all 4 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 residents and 3 staff and observed no issues with the files. LPA observed administrator certificate for Maria D Tavarez – 6028010740 with an expiration date of 08/25/2023.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the garage storage room.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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