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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600256
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:43:20 PM

Document Has Been Signed on 09/10/2024 03:43 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:HOME SWEET HOMEFACILITY NUMBER:
198600256
ADMINISTRATOR/
DIRECTOR:		CODRUTA PAULA VALEANUFACILITY TYPE:
740
ADDRESS:3342 COLD PLAINS DR.TELEPHONE:
(626) 333-4917
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 5CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator Codruta Paula Valeanu (Carol)TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst(s) (LPA) Jose Villalobos and Luis De Leon conducted an unannounced annual required inspection and met with Administrator Codruta Paula Valeanu (Carol) who allowed the entry of the facility. LPAs explained the reason of the visit. The facility is licensed to serve elderly residents age 60 and above. Fire clearance granted four (4) non-ambulatory and (1) bedridden. Facility may retain 3 hospice residents and has Dementia Plan in place.

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice hand washing constantly. The facility has submitted a COVID-19 Mitigation Plan and Infection Control plan. LPA to collect a copy.

2. Operational Requirement: The facility is cleared for four (4) non-ambulatory and one (1) bedridden. Currently all the residents are non-ambulatory. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

3. Physical Plant and Environmental Safety: The facility is a two story house and located in a residential neighborhood area. First floor, its included living room, dining area, kitchen, three residents bedrooms and one resident bathrooms and attached garage. On the second floor, the second floor is for the administrator and their family. LPA inspected all three residents bedrooms: required furniture and beddings were observed as well as sufficient lighting and closet space. Bathrooms observed to be clean, sanitary and in a good working condition. The bathroom also has required grab bar and non-skid mat. The hot water temperature tested in resident bathroom is 115 degrees F which is within the Title 22 regulation. The sharp knives and utensils are stored and inaccessible to residents. The cleaning supplies are stored also stored and inaccessible to residents. The facility has a land line telephone system. Fire alarms and C02 alarms observed. The walkway, passageway and patio are free of obstruction.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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: HOME SWEET HOME
FACILITY NUMBER: 198600256
VISIT DATE: 09/10/2024
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4. Staffing: The facility has sufficient staffing in the facility. Staff has updated CPR training. The administrator is living in the facility too, therefore she's always in the facility for night shifts.

5. Personnel Record Training: All the staff files are stored. The facility staff are all over 18 years old, associated with the facility and criminal background clearance. All staff does have the required training hours yearly. The facility administrator is Codruta Valeanu and her administrator certificate is active.

6. Resident Records-Incident Reports: The resident files are stored and locked. LPA reviewed all five (5) resident files and they all have the required documents which included: face sheet, pre-placement appraisal information, appraisal/needs and service plan, admission agreement, updated physician report and TB test, ambulatory status and medication list.

7.Residents' Right : The facility has all the required postings. The facility also has internet service shall provide at least one internet access device for resident use to face time with their families or entertainment.

8. Planned Activities: The facility does have sufficient space to accommodate both indoor and outdoor activities

9. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. All the food are stored probably. No residents are on modified diet that prescribed by the doctor.

10. Incident Medical and Dental: The resident medication are centrally stored and locked in the kitchen cabinet. LPA inspected all five (5) residents medication and they all seemed accurate and updated. Each resident has the 30 day supply mediation. Administrator will also provide medical and dental transportation if needed.

11. Disaster Preparedness: The facility has an updated disaster plan in place. The facility has two alternative temporary shelter location.

12. Residents with Special Health Needs: There are no residents with home health services. There are (2) residents on hospice. No resident is under restricted health condition or prohibited health condition.

No deficiencies were observed during the visit. Exit Interview conducted and A copy of the report was provided to Administrator
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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