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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607320
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:51:17 AM

Document Has Been Signed on 11/14/2024 11:51 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CERRITOS VILLA 1FACILITY NUMBER:
197607320
ADMINISTRATOR/
DIRECTOR:		JULIO NAVALLOFACILITY TYPE:
740
ADDRESS:16231 DRYCREEK LANETELEPHONE:
(562) 404-0767
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Mariquette Kurt CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a case management visit the purpose of this visit was to discuss documentation that had been submitted to LPA that was altered and or falsified. LPA met with Administrator Julio Navallo.

LPA received proof of corrections (POC) on 11/3/2024 for an annual visit conducted on 11/2/2024 that looked altered after verification it was discovered that S2-S3 CPR training had been falsified, staff training document were falsified and R6 physicians report had been falsified. LPA contacted Co-Administrator Maria Navallo on 11/6/2024 that stated that she didn’t not know how that happened and it must have been the staff. LPA tried contacting staff but has yet to receive a phone call back.

Deficiencies pertaining to Administrator Qualifications and prohibited health conditions are being cited on the attached LIC809D under the Title 22 California Code of Regulations, Division 6 Chapter 8.



Exit interview conducted with Administrator Julio Navallo. A copy of this report is being provided and Appeal Rights were provided.




SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 3
Document Has Been Signed on 11/14/2024 11:51 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 11/14/2024 at 10:24 AM
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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
Section Cited
CCR
87405(D)(5)

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87405(d)(5) Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(5) Good character and a continuing reputation of personal integrity.



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Administrator will call board meeting to discuss this issue. Administrator states he takes full responsibility and will ensure all training and POC’s are cleared by him. Administrator will have head caregiver assist with training logs.







Administrator will call board meeting to discuss this issue. Administrator states he takes full responsibility and will ensure all training and POC’s are cleared by him. Administrator will have head caregiver assist with training logs.






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This requirement has not been met as evidenced by:
Verification of staff CPR training, staff course training and physicians report for R6 submitted to LPA by Administrator were verified to be falsified and altered.



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Type B
11/21/2024
Section Cited
CCR87633(b)(4)

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87633(b)(4) Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.

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Administrator will submit a current care plan for R2 along with the responsibly of the facility of how to care for resident with a prohibit health condition,
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This requirement has not been met as evidenced by:
Facility did not have a current care plane for R2 for prohibited health condition.

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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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/14/2024 11:51 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 11/14/2024 at 11:10 AM
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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
Section Cited
CCR
87633(f)(1)

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87633(f)(1) Hospice Care of Terminally Ill Residents
(f)The licensee shall maintain a record of all hospice-related training provided to the licensee or facility personnel for a period of three years. This record shall be available for review by the Department.
(1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session.
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Administrator will send LPA training for staff by POC due date.
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This requirement has not been met as evidenced by:
Based on record review all staff had no training for prohibited health conditions.
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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