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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607954
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:13:17 PM

Document Has Been Signed on 09/12/2022 02:13 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DHANIELLA'S CARE HOMEFACILITY NUMBER:
197607954
ADMINISTRATOR:CIPRIANA L. ANCHETAFACILITY TYPE:
740
ADDRESS:1380 OAKHORNE DRIVETELEPHONE:
(310) 534-0187
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 2DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Administrator - Cipriana AnchetaTIME COMPLETED:
02:30 PM
NARRATIVE
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On 09/12/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by Administrator Cipriana Archeta and explained the purpose of today’s visit. The facility is licensed to serve six (6) elderly residents ages 60 and above who are non-ambulatory. The facility has a hospice waiver for one (1) resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, one (1) staff room, two (2) bathrooms, living area, dining area, kitchen, and outside patio area covered with an umbrella and ample seating in backyard. There were two (2) residents in the facility at the time of the visit.

LPA and Administrator Cipriana Archeta toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured between 110.3 F and 120 F in the kitchen sink and bathrooms.

There is an attached garage with access to garage from a door prior to entering the facility or through the garage door. The washer and dryer is located in the garage. There is also a second refrigerator/freezer and a third freezer located in the garage. The garage is used for storage and no cars are parked in the garage.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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 11
Document Has Been Signed on 09/12/2022 02:13 PM - It Cannot Be Edited


Created By: Don Senaha On 09/12/2022 at 12:58 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Resident #2 (R2) identified on hospice and admitted on 08/21/22. The facility is only approved for one (1) hospice waiver and is now operating with two (2) hospice residents beyond the conditions and limitations specified on the license. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee agrees to submit a hospice waiver request to CCLD by POC due date of 9/13/22 and understands that it is their responsibility to follow up on waiver requests and hospice residents should not reside at the facility until a hospice waiver has been granted by CCLD.
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Room #3 smoke detector was not operational during inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee immediately replaced the battery/fixed the smoke detector to ensure it works properly.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 09/12/2022 02:13 PM - It Cannot Be Edited


Created By: Don Senaha On 09/12/2022 at 12:58 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee had cleaning solutions and disinfectants unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee immediately removed and locked all cleaning solutions and disinfectants during visit on 9/12/22.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee had unlocked medications in a storage area near the dining room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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Licensee immedicately removed and locked all cleaning solutions and disinfectants during visit on 9/12/22.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


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Document Has Been Signed on 09/12/2022 02:13 PM - It Cannot Be Edited


Created By: Don Senaha On 09/12/2022 at 12:58 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee uses a lighter to start stove burners which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2022
Plan of Correction
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Licensee to fix, repair or replace stove and send LPA video and receipt if new purchase by POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Room #2 and #3 had broken screen sliding doors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2022
Plan of Correction
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Licensee to fix, repair or replace and send LPA video and receipt if new purchase by 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 09/12/2022 02:13 PM - It Cannot Be Edited


Created By: Don Senaha On 09/12/2022 at 12:58 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee had plants/grass growing over the walk way on the side of the house and a hole in the cement where a tree was taken out where a resident can trip and fall which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2022
Plan of Correction
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Licensee will cut plants/grass back to clear passageway and fill the hole from a tripping hazard.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


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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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: DHANIELLA'S CARE HOME
FACILITY NUMBER: 197607954
VISIT DATE: 09/12/2022
NARRATIVE
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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins were unlocked and accessible to resident. See 809D page. The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. There is one (1) fire extinguisher fully charged in the kitchen area. Smoke detectors and carbon monoxide were tested. One smoke detector in room #2 was non operational. See 809D page. There was a first aid kit available stored in the kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed all mandated inspection control posters were posted.

Advisory Notes – Five (5) Technical Assistance were issued, please see LIC9102-AN.

There were seven (7) deficiencies cited during this inspection visit. See 809D pages.

An exit interview was conducted and a copy of this report was provided to Administrator Cipriana Archeta.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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