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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607320
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:15:01 PM

Document Has Been Signed on 12/07/2021 02:15 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 VILLA 1FACILITY NUMBER:
197607320
ADMINISTRATOR:JULIO NAVALLOFACILITY TYPE:
740
ADDRESS:16231 DRYCREEK LANETELEPHONE:
(562) 404-0767
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 4DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maria Alda Navallo Farren - RN ConsultantTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Guillernia Hernandez and explained the reason for the visit. The RN Consultant Maria Alda Navallo Farren arrived shortly after. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected. Facility is licensed to serve 6 non-ambulatory residents age 60 and above and may retain one hospice resident. Facility has an approved fire clearance for one bedridden resident.

LPA and Caregiver Guillernia Hernandez toured the facility which included the following: front yard patio, living room, dining area, kitchen, 2 bathrooms, 4 resident rooms, attached garage and backyard. Passageways and exits are free of obstruction. The water temperature was tested in the 2 resident bathrooms and measured between 110 - 112 degrees F which is within the required 105 - 120 degrees F. The resident 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. Resident beds have the required linen and the linen is in good condition. Bedrooms also have sufficient closet space. There is extra linen in a closet near the dining area and a cabinet in the hallway. Smoke detectors were tested and observed throughout the facility and in each resident room. Carbon monoxide detector was tested and observed in the dining area. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 2 fire extinguishers in the kitchen and hallway which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps and cleaning chemicals are locked under the kitchen sink and are inaccessible to residents. The First Aid kit was inspected and is fully stocked with current manual, and it is locked in a cabinet near the kitchen. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen and garage. Medications, resident files, and staff files are kept in a locked cabinet near the kitchen. (CONTINUED TO LIC809C)
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CERRITOS VILLA 1
FACILITY NUMBER: 197607320
VISIT DATE: 12/07/2021
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The front yard patio and backyard are clean and there is a shaded seating area for the residents. No bodies of water were observed at the facility.

LPA reviewed 5 staff files and observed the following: 5 out of 5 staff have criminal record clearances, 5 out of 5 staff have proof of in-service training, 5 out of 5 staff files have health screenings with TB information, and 1 out of 5 staff have current first aid/CPR certificates. Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Staff 4 (S4) did not have a current CPR/First Aid training certificate in their file.

LPA reviewed 4 residents files and medications, and observed the following: 4 out of 4 resident have admission agreements on file, 4 out of 4 have their needs and services plans up to date, and 4 out of 4 have physician's reports on file and TB information, and 4 out of 4 have their medications documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit (refer to LIC809D). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2021 02:15 PM - It Cannot Be Edited


Created By: Luis Mora On 12/07/2021 at 02:07 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 VILLA 1

FACILITY NUMBER: 197607320

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements: (c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 4 out of 5 staff files. S1, S2, S3, and S4 did not have a current CPR/First Aid training in their files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2021
Plan of Correction
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Administrator will ensure that all staff providing care have a current CPR/First Aid training and submit a copy of the certificate by 12/14/2021.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021


LIC809 (FAS) - (06/04)
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