198600290-1-31-2025-28-AS-NMAN-DDG3ES-20250131171137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600290
Report Date: 01/31/2025
Date Signed: 01/31/2025 05:11:52 PM

Document Has Been Signed on 01/31/2025 05:11 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:	ASUNCION BOARD & CARE		FACILITY NUMBER:	198600290
ADMINISTRATOR/ DIRECTOR:	ROSEMARIE A. ZIMMER		FACILITY TYPE:	740
ADDRESS:	1636 S. RAMA DRIVE		TELEPHONE:	(626) 338-0772
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 6		CENSUS: 3	DATE:	01/31/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Rosemarie Honrado		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with the Administrator Rosemarie Honrado and Licensee Adelaida Asuncion. LPA explained the purpose of the visit. During the visit, the CARE tool was used. The facility is licensed to serve Dementia residents, ages 60 and above, approved for two (2) non-ambulatory and four (4) ambulatory residents. Currently, there is no hospice resident in placement.
The facility is a single-story house located in a residential neighborhood. It consists of five (5) bedrooms including three (3) resident bedrooms, one (1) staff room, one (1) room for family member; three (3) bathrooms, kitchen, dining room, living room, and detached garage. Facility was toured, staff/residents files were reviewed. Residents medications were reviewed. No pools and bodies of water on the premises. All residents' bedrooms and bathrooms were inspected. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. The common areas are clean and have the required furniture. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested and was measured within Title 22 Regulation guidelines. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space.
The kitchen was inspected. LPA observed that kitchen equipments are in working condition but the stove and refrigerator were dirty with oil stains all over. Kitchen cabinets also needed cleaning. LPA observed sufficient supply of perishable and non-perishable foods. There is additional food in the refrigerators located in the garage. Adequate linen and personal hygiene supplies was observed. Auditory alarm devices to monitor exits were operable. Last fire drill was conducted on 12/07/24. Knives and sharps are locked in the kitchen and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguisher observed in the dining room and fully charged.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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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Document Has Been Signed on 01/31/2025 05:11 PM - It Cannot Be Edited

Created By: Nune Margaryan On 01/31/2025 at 04:24 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASUNCION BOARD & CARE	FACILITY NUMBER: 198600290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Based on observation the stove, refrigerator and kitchen cabinets in the kitchen was dirty with oil stains all over, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/05/2025
	Plan of Correction
1 2 3 4	Licensee is to ensure clean the kitchen appliances and kitchen cabinets. Proof / pictures will be send to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Wei Siew Ho

LICENSING EVALUATOR NAME:

Nune Margaryan

LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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: ASUNCION BOARD & CARE	FACILITY NUMBER: 198600290
	VISIT DATE: 01/31/2025

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Laundry area was observed in the covered patio between the house and garage. Laundry detergents were observed locked next to the washer and dryer and in the garage. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet; resident and staff records are stored in a locked room and both inaccessible to residents. First Aid kit was fully stocked with current manual. LPA reviewed 3 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Two staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed are documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided to Adelaida Asuncion.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

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