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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800430
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:19:14 PM

Document Has Been Signed on 12/06/2024 12:19 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:OASIS OF LOVE PLAZA CAREFACILITY NUMBER:
197800430
ADMINISTRATOR/
DIRECTOR:		LAURA IGNACIOFACILITY TYPE:
740
ADDRESS:2993 BAYBERRY COURTTELEPHONE:
(909) 217-7866
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 4DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Caregiver Queen AlimarioTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 12/06/2024 and was greeted by Caregiver Queen Alimario. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants and cleaning solutions that could pose a danger if readily available to residents, were observed to be accessible to residents in bathrooms and under kitchen cabinet. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be 130.3 degrees F, during inspection. LPA Ramirez asked how water temperature is measured to ensure it does not rise above 120 degree F. Staff revealed the facility does not have equipment to check water temperature. Staff lowered broiler during visit. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies.

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Four (4) out of the four (4) residents attend a day program.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 08/17/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in garage.



See 809-C
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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
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: OASIS OF LOVE PLAZA CARE
FACILITY NUMBER: 197800430
VISIT DATE: 12/06/2024
NARRATIVE
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Residents with Special Needs: No large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medications cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.



Staffing: Administrator Certificate for Laura Ignacio is pending renewal. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for six (6) non-ambulatory.

Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

Two (2) violations were observed and cited during inspection. Exit interview conducted. A copy of this report, 809-D and appeals was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 12:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/06/2024 at 11:50 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: OASIS OF LOVE PLAZA CARE
FACILITY NUMBER: 197800430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temps in bathrooms were measured to be 130.3 degree F, the licensee did not comply with the section cited above in [count] out of 4 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Staff lowered facility broiler during visit. *LPA Ramirez observed water temperature to be under 120 degree F before leaving the facility. This clears 24HR correction.* Licensee will retrain staff on this regulation and send proof of training by 12/11/2024, via email.
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, disinfectants and cleaning solutions were observed to be accessible in bathrooms and under kitchen cabinet sink, the licensee did not comply with the section cited above in 4 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Staff placed a lock on cabinets during inspection *This clears 24HR correction.* Licensee will re-train staff on this regulation and send proof of re-training by 12/11/24, via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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