197607854-3-28-2023-28-AS-ALOZ-CQCU6B-20230328151805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607854
Report Date: 03/28/2023
Date Signed: 03/28/2023 03:18:30 PM

Document Has Been Signed on 03/28/2023 03:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	IMPERIAL CARE		FACILITY NUMBER:	197607854
ADMINISTRATOR:	IRENE B. IMPERIAL		FACILITY TYPE:	740
ADDRESS:	18423 NORAN AVENUE		TELEPHONE:	(562) 402-4444
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY: 6		CENSUS:	DATE:	03/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Irene B Imperial		TIME COMPLETED:	03:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA's ) Alberto Lopez and Tena Herrera conducted the required annual inspection. LPA's arrived unannounced and met with Licensee Irene Imperial and Administrator Nicanon Imperial who assisted with the visit. The purpose for the visit was explained. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for 6 ambulatory residents of which 5 may be non-ambulatory and one bedridden. There is a hospice waiver approved for 1 residents. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 3 non-ambulatory residents and 1 ambulatory resident residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: . There are 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. But knives and cleaning solutions were stored together. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathroom and kitchen were measured between 113.0-114.6 degrees F which are within the required range of 105-120 degrees.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IMPERIAL CARE	FACILITY NUMBER: 197607854
	VISIT DATE: 03/28/2023

NARRATIVE

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Staffing: There appears to be sufficient staffing at the facility. The administrator’s Irene Imperial expires 03/06/2024 Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted during visit.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. Knifes are stored together with cleaning supplies that may cause cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA's reviewed all 4 residents' medication and did not observe some PRN to have labels attached to bottles administered and PRN letters not in resident’s file.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia. The staff received training on appropriately caring for residents with dementia, and receiving oxygen.
During the visit today, LPAs observed no deficiencies at time of visit. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Co-Administrator Irene Imperial

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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